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TWENTIETH  CENTURY 

PEACTICE 

AN  INTERNATIONAL  ENCYCLOPEDIA 

OF 

MODERN  MEDICAL  SCIENCE 

BY 

LEADING  AUTHORITIES  OF  EUROPE  AND  AMERICA 


EDITED  BY 


THOMAS   L.   STEDMAN,  M.D. 


NEW   YORK   CITY 


IN  TWENTY  VOLUMES 

VOLUME    I. 

DISEASES    OF    THE    UROPOIETIC    SYSTEM 


NEW  YORK 
WILLIAM   WOOD  AND   COMPANY 

1895 


Copyright,  1895, 
By  WILLIAM  WOOD  &  COMPANY 


PRESS   OF 

THE    PUBLISHERS'    PRINTING    COMPANY 

132-136    W.     FOURTEENTH  ST. 

NEW    YORK 


PREFACE. 


To  those  who  realize  the  many  and  radical  changes  that  have 
taken  place  in  the  healing  art  during  the  closing  years  of  this  century 
no  apology  is  needed  for  the  work  here  presented.  Within  but  little 
over  a  decade  a  new  science  has  arisen  and  a  new  theory  of  infec- 
tious diseases  has  been  established,  while  the  advances  made  in  many 
other  branches  of  internal  medicine  have  been  hardly  less  remark- 
able. Indeed  it  is  not  too  much  to  say  that  a  new  era  has  be- 
gun, one  in  which  the  rational  treatment  of  disease  engages  the 
best  thought  of  the  best  workers,  supplementing,  while  not  supplant- 
ing, the  study  of  pathological  anatomy  by  which  the  preceding  era 
was  characterized.  The  science  of  medicine  has  been  in  great  part 
recast — the  time  is  now  ripe  for  it  to  be  rewritten.  To  this  end  the 
co-operation  of  many  recognized  authorities  in  Europe  and  America 
has  been  secured,  the  results  of  whose  labors  will  be  presented  in 
the  successive  volumes  of  this  series. 

In  arranging  the  order  of  subjects  it  has  been  thought  best  to  re- 
serve the  consideration  of  infectious  diseases  for  the  later  volumes,  in 
the  hope  that  by  the  time  they  are  published  a  solution  of  some  of 
the  problems  in  the  pathogenesis  and  therapy  of  these  affections,  as 
yet  but  partially  worked  out,  will  have  been  reached.  While  the 
published  schema  of  the  work  will  be  as  far  as  possible  adhered  to, 
circumstances  may  comj)el  a  rearrangement  of  the  articles,  or  even  a 
change  in  the  order  of  jmblication  of  the  volumes.  Such  changes 
will  not,  however,  affect  the  completed  work. 

The  editor  gladly  embraces  this  opportunity  to  express  his  grate- 
ful appreciation  of  the  kindly  readiness  with  which  the  collaborators 
have  resi)onded  to  his  invitation  to  assist  in  the  work.  To  the 
ptublishers  are  due  his  thanks  for  the  uniform  courtesy,  generous 
acquiescence,  and  helpful  suggestion,  which  have  contributed  in  no 
small  measures  to  lighten  his  labors.  It  is  his  pleasant  duty  also  to 
acknowledge  his  indebtededness  for  valued  counsel  to  Drs.  Bulkley, 


IV  PEEFACE. 

Dana,  and  Shrady,  of  New  York,  Prosser  James,  of  London,  and  von 
Noorden,  of  Frankfort  o.  M.  To  Dr.  Albert  H.  Buck  especially  is 
lie  under  deep  obligation  not  only  for  advice  and  encouragement  in 
tlie  present  undertaking,  but  also  for  many  kindnesses  of  a  like  nature 
in  tbe  past. 

T.  L.  S. 

New  Yokk,  January  30,   1895. 


CONTENTS. 


PAGE 

Diseases  of  the  Kidneys, .  1 

The  Urine, 20 

Dropsy,        .        .        .        . 23 

Albuminuria,        .         .         .    - .26 

Uraemia,        .............  29 

Acute  Congestion  of  the  Kidneys,         .         .         .         .         .         .         .         .38 

Chronic  Congestion  of  the  Kidneys,      ........  40 

Acute  Degeneration  of  the  Kidneys, 45 

Chronic  Degeneration  of  the  Kidneys, 49 

Acute  Exudative  Nephritis, 52 

Acute  Productive  (or  Diffuse)  Nephritis, 62 

Chronic  Productive  (or  Diffuse)  Nephritis  with  Exudation,  .         .         .69 

Chronic  Productive  Nephritis  without  Exudation,        .         .         .         .         .86 

Puerperal  Eclampsia, 100 

Suppurative  Nephritis, 103 

Tubercular  Nephritis, 106 

New  Growths  of  the  Kidney, '.         .  107 

Bibliography, 109 

Diseases  of  the  Kidneys  (Stjkgical)  and  of  the  Ueeters,  .         .        .111 

Injuries  of  the  Kidneys, 113 

Movable  Kidney, 118 

Perinephritic  and  Nephritic  Suppurations, 120 

Surgical  Kidney, 122 

Hydronephrosis, 127 

Pyonephrosis, 134 

Eenal  Calculus, 137 

Renal  Tuberculosis, 152 

Deformities  and  Malpositions  of  the  Kidneys,       , 159 

Hydatid  of  the  Kidney, 162 

Tumors  of  the  Kidney, 165 

Injuries  of  the  Ureters, 172 

Obstruction  of  the  Ureters, 181 

Congenital  and  Acquired  Malformations  of  the  Ureters,        ....  194 

Ureteral  Fistulas, 198 

Bibliography, 199 

Diseases  of  the  Bladder, 201 

Rupture  and  Injuries  of  the  Bladder,            203 

Foreign  Bodies  in  the  Bladder, 212 


VI 


CONTENTS. 


Prostatic  Origin 


Inflammation  of  the  Bladder, 

Malformations  and  Structural  Alterations  in  the  Form  of  the  Bladder, 

Endemic  Haematuria, 

Sinuses  Connected  with  the  Bladder,    . 

Stone  in  the  Bladder,    ..... 

Bibliography, 

Diseases  or  the  Prostate,        ... 

Anomalies  of  Development, 

Injuries  of  the  Prostate, 

Neuroses  of  the  Prostate  and  Reflex  Neuroses  of 

Hyperaemia  of  the  Prostate, 

Acute  Prostatitis, 

Chronic  Prostatitis,       ..... 

Tuberculosis  of  the  Prostate, 

Cancer  of  the  Prostate, 

Calculus  of  the  Prostate,       .... 

Hypertrophy  of  the  Prostate, 

Bibliography,        ...... 

Diseases  OF  THE  Male  Urethra, 

Injuries  of  the  Urethra,         .... 

Foreign  Bodies  in  the  Urethra,     . 

Acute  Urethritis,  ..... 

Gonococcal  or  Specific  Urethritis, 

Complications  of  Urethritis, 

Chronic  Urethritis 

Stricture  of  the  Urethra,       .... 

Spasmodic  Stricture,     ..... 

Congestive  or  Inflammatory  Stricture, 

Organic  Stricture,         ..... 

Bibliography,        ...... 

Diseases  of  the  Urine,     ..... 

Haematuria,  ...... 

Pyuria, 

Accidental  Albuminuria,       .... 

Cystinuria,   ....... 

Phosphaturia,        ...... 

Oxaluria,      .         .         .         .         .         .         . 

Polyuria, 

Chyluria, 

Bibliography,        ...... 

Diseases  of  the  Female  Bladder  and  Urethra, 

Anatomy, 

Methods  of  Examining  the  Female  Urinary  Organs, 

Diseases  of  the  Urethra, 

Diseases  of  the  Bladder, 
Index, 


CONTRIBUTORS   TO   VOLUME  I. 


Feancis  Delapeeld,  M.D.,  LL.D.,  New  York. 

Professor  of  the  Practice  of  Medicine,  Medical  Department  of  Columbia  Col- 
lege ;  Visiting  Physician  to  Roosevelt  Hospital ;  Consulting  Physician  to 
Bellevue  Hospital. 

E.  HuEEY  Fenwick,  E.E.C.S.,  London. 

Surgeon  to,  and  Lecturer  on  Clinical  Surgery  at,  the  London  Hospital ;  Sur- 
geon to  St.  Peter's  Hospital  for  Urinary  Diseases ;  Consulting  Surgeon  to 
the  West  Herts  Infirmary. 

Reginald  Haeeison,  F.R.C.S.,  London. 

Surgeon  to  St.  Peter's  Hospital  for  Urinary  Diseases. 

HowAED  A.  Kelly,  M.D.,  Baltimore. 

Professor  of  Gynecology  and  Obstetrics,  Johns  Hopkins  University ;  Gyne- 
cologist and  Obstetrician  to  the  Johns  Hopkins  Hospital. 

G.  Feank  Lydston,  M.D.,  Chicago. 

Professor  of  Genito-Uriuary  Surgery  and  Syphilology,  College  of  Physicians 
and  Surgeons ;  Medical  Director  of  the  Masonic  Hospital. 


DISEASES  OF  THE  KIDNEYS. 


BY 


FRANCIS  DELAFIELD, 


NEW  YORK. 


DISEASES  OF  THE  KIDNEYS. 


The  kidneys  are  deeply  seated  in  the  lumbar  region,  lying  one  on 
eacli  side  of  the  vertebral  column,  behind  the  peritoneum.  They 
measure  about  4  inches  in  length,  2^  inches  in  breadth,  and  1^  inch 
or  more  in  thickness.  The  left  is  usually  longer  and  narrower  than 
the  right.  The  weight  of  each  kidney  is  usually  stated  to  be  about 
4|-  ounces  in  the  male,  and  somewhat  less  in  the  female. 

It  is  exceedingly  difficult  to  reach  any  certain  results  by  per- 
cussion as  to  the  size,  or  even  as  to  the  presence,  of  the  kidneys. 
Auscultatory  percussion  is  much  more  valuable  for  this  purpose  than 
is  simple  percussion.  Palpation  is  used  with  the  patient  lying  on 
his  back.  Any  considerable  enlargement  or  displacement  of  the 
kidney  can  be  made  out  in  this  way. 

Each  kidney  is  enclosed  in  a  connective-tissue  capsule,  the  blood- 
vessels of  which  are  continuous  with  those  of  the  cortex.  In  healthy 
kidneys,  when  the  capsules  are  stripped  off  the  surfaces  of  the  kidneys 
are  left  smooth  except  at  the  points  where  the  blood-vessels  are  broken 
off.  If,  however,  there  has  existed  a  nephritis  which  has  involved 
the  stroma  of  the  kidney,  when  the  capsule  is  stripped  off  the  surface 
is  left  torn  and  roughened. 

The  kidneys  are  composed  of  two  portions — the  cortical,  which 
performs  the  excreting  functions  of  the  kidney,  and  the  pyramidal, 
which  conveys  the  urine  to  the  calyces.  Their  component  parts 
are :  the  uriniferous  tubes,  blood-vessels,  glomeruli,  lymphatics,  and 
stroma. 

Each  uriniferous  tube  begins  in  a  glomerulus  at  some  point  in  the 
cortex  of  the  kidney.  The  tube  is  at  first  of  large  size,  is  arranged  in 
convolutions,  and  is  lined  with  large  epithelial  cells  which  are  closely 
joined  together,  have  a  thin  and  fragile  limiting  membrane  and  a  cell 
body  which  is  easily  changed  by  preservative  fluids.  As  the  tube 
approaches  the  pyramidal  portion  of  the  kidney  its  course  becomes 
straighter  and  its  calibre  smaller,  it  runs  down  into  the  pyramid  for 
a  considerable  distance,  then  turns  upon  itself,  forming  a  loop 
(Henle's  loop),  and  goes  back  into  the  cortex.  The  loop  portion 
of  the  tubes  is  lined  with  flattened  cells  having  an  oval,  bulging 
nucleus.     After  the  tube  has  again  reached  the  cortex  it  becomes 


4  PET/ A  FIELD — DISEASES  OF  THE  KIDNEYS. 

larger,  runs  in  a  straight  line  nearly  up  to  tlie  surface  of  the  kidney, 
and  is  lined  with  large  epithelial  cells  of  which  the  limiting  mem- 
branes are  more  distinct  and  the  cell  bodies  more  resistant  than  is  the 
case  in  the  convoluted  tubes.  Now  the  tube  again  becomes  convo- 
luted for  a  short  distance,  then  runs  a  straight  course  down  through 
the  cortex  into  the  pyramid.  In  the  pyramid  it  joins  one  of  the  large 
collecting  tubes  and  so  finally  reaches  its  outlet  into  a  calyx.  The 
tubes  in  the  pyramids  are  lined  with  large  epithelial  cells,  having  a 
very  distinct  limiting  cell  membrane  and  very  resistant  cell  bodies. 

The  renal  arteries  are  large  in  proportion  to  the  size  of  the  kid- 
neys. Each  artery  divides  into  four  or  five  branches  which  pass  in  at 
the  hilus,  penetrate  the  substance  of  the  organ  between  the  papillae, 
enter  the  cortex  between  the  pyramids,  subdividing,  until  they  reach 
the  bases  of  the  pyramids  where  they  form  arches.  From  these  are 
given  off  small  arteries  which  run  straight  up  into  the  cortex,  and  from 
these  arteries  are  given  off  the  little  branches  to  the  glomeruli. 

The  efferent  veins  from  the  glomeruli  are  continuous  with  a  system 
of  capillaries  surrounding  the  cortex  tubes  which  empty  into  veins 
running  parallel  with  the  straight  arteries  in  the  cortex.  There  are 
also  many  veins  and  venous  capillaries  in  the  pyramids.  All  empty 
into  the  large  renal  vein  which  joins  the  inferior  vena  cava. 

The  glomeruli  are  formed  of  a  capsule  and  an  enclosed  tuft  of 
small  blood-vessels.  The  capsule  is  continuous  with  the  basement 
substance  of  a  uriniferous  tube,  and  is  lined  with  a  continuous  layer 
of  flat  endothehal  cells.  The  tuft  is  composed  of  vessels  of  capillary 
size,  but  with  rather  thick  walls.  Their  endothelial  lining  does  not 
seem  to  be  continuous  as  it  is  in  most  capillaries.  Their  outer  sur- 
faces are  covered  with  a  continuous  layer  of  flat,  nucleated  cells. 

The  cortical  portion  is  composed  of  bundles  of  straight  tubes  and 
of  convoluted  tubes  and  glomeruli,  alternating  with  each  other.  The 
stroma  is  delicate  and  scanty  in  the  cortex,  firmer  and  more  abun- 
dant in  the  pyramids.  In  most  adult  kidneys  there  are  little  areas  of 
connective  tissue  scattered  in  the  cortex  close  under  the  capsules.  The 
lymphatics  are  numerous,  and  consist  of  a  superficial  and  a  deep  set. 

It  is  the  function  of  the  kidneys  to  remove  from  the  body  fluid  and 
excrementitious  substances.  It  is  generally  believed  that  the  fluid 
is  discharged  by  the  glomeruli,  and  the  excrementitious  substances 
separated  from  the  blood  by  the  epithelium  of  the  cortex  tubes. 

It  is  evident  that  for  the  proper  performance  of  the  functions  of 
the  kidneys  there  must  be :  (1)  A  free  supply  of  blood  to  the  kidney, 
a  free  circulation  of  blood  through  it,  and  an  easy  escape  of  blood 
through  the  renal  vein.  Any  obstruction  to  the  flow  of  blood,  any 
changes  in  the  tufts  of  the  glomeruli,    and  any   obliteration  of  the 


CLASSIFICATION  OF  DISEASES  OF  THE  KIDNEY.  5 

capillaries  interfere  with  the  fuiictions  of  the  kidneys.  (2)  The 
blood  supplied  to  the  kidney  must  be  of  normal  composition;  other- 
wise there  will  be  a  change  in  the  character  and  quantity  of  the 
substances  excreted.  (3)  The  uriniferous  tubules  must  be  of  normal 
size  and  unobstructed.  The  epithelial  cells  which  line  them  must 
be  healthy. 

The  study  of  the  diseases  of  the  kidney  is,  therefore,  a  study  of  the 
changes  in  the  circulation  of  the  blood  in  these  organs,  of  the  composi- 
tion of  the  blood  which  is  supplied  to  them,  and  of  anatomical  changes 
affecting  the  tubes,  the  stroma,  the  glomeruli  and  the  blood-vessels. 

Classification  of  Diseases  of  the  Kidney. 

The  recognition  of  the  diseases  of  the  kidney,  which  still  bear  the 
name  of  their  discoverer,  dates  back  only  to  the  year  1827,  when 
Richard  Bright  published  his  first  paper  on  the  subject.  This  first 
paper  was  followed  by  others,  and  in  1829  Christison  pubHshed  in  the 
Edinburgh  Medical  and  Surgical  Beview  his  account  of  the  same  dis- 
ease. Both  these  authors  regarded  the  disease  as  a  morbid  change  in 
the  kidneys,  which  was  the  cause  of  the  accompanying  symptoms. 

In  1841  Bayer  completed  his  large  atlas  of  colored  plates  and  de- 
scription of  kidney  diseases.      His  classification  is  as  follows: 

1.  Nephritis — an  inflammation  of  the  cortical  or  tubular  portion 
of  the  kidneys :  (a)  Simple  nephritis ;  (6)  Gouty  nephritis ;  (c) 
Bheumatic  nephritis;  {d)  Nephritis  produced  by  poison;  (e)  Albu- 
minous nephritis; 

2.  Pyelitis; 

3.  Perinephritis. 

In  1842  Bokitansky  recognized  the  waxy,  or  amyloid,  kidneys  as 
presenting  different  lesions  from  those  found  in  other  examples  of 
kidney  disease. 

In  1851  Frerichs  published  his  monograph  on  Bright' s  disease, 
and  gave  a  systematic  description  which  has  had  a  decided  effect  on 
the  minds  of  most  subsequent  observers.  His  conception  is  that  of 
one  disease — Bright 's  disease,  with  a  characteristic  lesion — inflam- 
mation of  the  kidneys.  The  varieties  of  the  disease  depend  upon  the 
stages  of  the  inflammation.     There  are  three  stages : 

1.  The  stage  of  hypersemia  and  of  commencing  exudation. 

2.  The  stage  of  exudation  and  of  commencing  transformation  of 
the  exudation. 

3.  The  stage  of  atrophy. 

1.  Hyperoimia. — The  first  stage  is  characterized  by  an  increase  in 
the  size  of  the  kidneys,  especially  of  the  cortex,  by  general  congestion, 


6  DEIAPIELD — DISEASES  OP  THE  KIDNEYS. 

by  extravasations  of  blood  in  tbe  Malpigliian  bodies,  the  tubes,  and 
tlie  kidney  tissue,  and  by  filling  of  the  tubes  with  coagulated  fibrin. 
The  epitbelium  of  tfie  tubes  is  unaltered. 

2.  Exudation. — In  the  second  stage,  tlie  congestion  diminislies 
while  the  exudation  increases.  The  exudation  is  found  in  the  tubules 
and  in  the  interstitial  tissue.  The  exudation  between  the  tubes  is 
sometimes  organized  into  connective  tissue.  The  cortex  becomes  of 
a  white-j^ellowish  color,  and  remains  thickened.  The  surface  of  the 
kidney  is  smooth  or  slightly  granular.  The  pyramids  are  of  a  red- 
dish color.  Some  of  the  Malpighian  bodies  are  normal,  others  are 
enlarged  and  filled  mth  exudation.  In  the  cortex  the  eiDithelium  of 
the  tubes  is  swollen  and  granular,  and  may  break  down  altogether,  or 
it  simply  shrivels  and  atrophies.  The  tubes  are  filled  with  degener- 
ated epithelium,  granular  matter,  and  fat-globules,  or  with  homoge- 
neous exudation.  The  tubes  are  dilated.  The  dilatation  of  the  tubes 
is  the  principal  or  only  cause  of  the  increased  size  of  the  kidney. 

3.  Atrophy. — In  the  third  stage,  the  kidneys  are  smaller,  or  of 
normal  size,  or  even  larger  than  normal.  The  capsule  is  adherent. 
The  surface  of  the  kidney  is  irregular  and  granular,  its  color  a  dusky 
yellow.  Its  consistence  is  hard.  The  cortex  is  thinned.  The  pyra- 
mids are  smaller.  The  fat  about  the  pelvis  is  increased  in  amount. 
The  tubes  are  dilated  and  filled  as  in  the  second  stage,  or  are  col- 
lapsed and  folded  together.  Most  of  the  Malpighian  bodies  are 
shrivelled  and  fatty.  If  the  exudation  between  the  tubes  has  become 
organized,  we  find  masses  of  connective-tissue  cells  and  fibres. 

This  description  of  the  lesions,  taken  as  it  was  from  nature,  is  as 
true  now  as  when  it  was  written.  But  yet  our  present  pathological 
knowledge  makes  us  interjjret  these  lesions  somewhat  differently. 

In  1852  Dr.  George  Johnson  published  a  -sVork  on  kidney  diseases 
which,  like  that  of  Frerichs,  has  had  a  durable  effect  on  medical 
opinions.     He  distinguishes  five  forms  of  Bright's  disease. 

1.  Acute  Desquamative  Nephritis. — The  form  of  disease  occurring 
after  scarlet  fever,  exposure  to  cold,  etc.  This  corresponds  to  Fre- 
richs' first  stage.  Johnson,  however,  lays  most  stress  upon  the  de- 
squamation of  the  epithelium,  and  but  little  on  the  exudation  in  the 
tubes.     Exudation  between  the  tubes  he  does  not  mention. 

2.  Chronic  Desquamative  Nephritis. — This  corresponds  to  the  sec- 
ond and  third  stages  of  Frerichs.  Johnson  describes  the  degenera- 
tion of  the  epithelium,  the  denudation  of  the  tubes  of  their  epithe- 
lium, their  dilatation  and  collapse,  and  the  presence  of  coagulated 
material  within  them.  The  Malpighian  tufts  are  thickened  or 
atrophied.  The  arteries  are  thickened.  He  regards  the  production 
of  new  fibrous  tissue  as  an  accidental  and  unessential  phenomenon. 


CLASSIFICATION  OF  CrSEASES   OF  THE   KIDNEY.  7 

3.  Waxy  Degeneration  of  the  Kidney. — Under  this  name  Jolinson 
describes  kidneys  whicli  are  of  large  size,  their  cortex  thick  and  white, 
their  tubes  filled  with  waxy  material.  This  waxy  material  he  sup- 
poses to  be  produced  by  a  degeneration  of  the  epithelium.  The  large 
hyaline  casts  found  in  the  urine  he  calls  waxy,  and  seems  to  consider 
them  diagnostic  of  this  form  of  kidney  disease. 

4.  Acute  Non-desquamative  Disease  of  the  Kidneys. — This  is  char- 
acterized during  life  by  scanty  or  suppressed  urine,  but  containing 
no  albumin,  and  no  casts,  or  only  a  few  waxy  ones.  The  kidneys 
are  of  normal  size ;  the  epithelium  of  the  tubes  is  somewhat  altered. 

5.  Chronic  Non-desquamative  Disease. — The  kidneys  are  usually 
large,  very  rarely  atrophied.  The  cortex  is  thick  and  white.  The 
convoluted  tubes  are  more  opaque  than  usual.  The  Malpighian  bodies 
and  arteries  are  thickened. 

6.  The  Granular  Fat  Kidney. — This  form  may  be  a  consequence 
of  the  non-desquamative  disease,  of  acute  desquamative  inflammation, 
and  rarely  of  chronic  desquamative  disease.  The  kidneys  are  large, 
the  cortex  white,  mottled  with  yellowish  granulations.  These  yellow 
granulations  are  formed  of  tubes  containing  oil-globules.  The  ves- 
sels and  Malpighian  bodies  are  thickened.  Sometimes  the  same  yel- 
low, fatty  granulations  are  found  in  atrophied  kidneys. 

7.  The  Mottled  Fat  Kidney. — All  the  tubes  of  the  cortex  contain 
oil-globules,  and  there  are  red  spots  of  congestion  or  extravasation. 

To  Traube  (1856)  belongs  the  merit  of  recognizing  chronic  con- 
gestion of  the  kidney  as  a  lesion  with  an  entirely  different  cause  from 
that  of  other  forms  of  Bright' s  disease;  and  also  of  calling  attention 
to  the  fact  that  blood-contamination  cannot  be  the  only  cause  of  the 
cerebral  symptoms. 

In  1858  Yirchow,  in  his  "Cellular  Pathology,"  developed  the  doc- 
trine that  in  Bright' s  disease  either  the  tubes,  the  stroma,  or  the 
Malpighian  bodies  are  principally  involved,  and  that  we  can,  there- 
fore, distinguish  a  parenchymatous  nephritis,  an  interstitial  neph- 
ritis, and  an  amyloid  degeneration  of  the  kidney.  This  doctrine 
has  had  a  lasting  effort  on  all  subsequent  classifications. 

Grainger  Stewart  distinguishes : 

1.  The  Inflammatory  Form. — This  has  three  stages:  (1)  That  of 
inflammation;  (2)  That  of  fatty  transformation;  (3)  That  of  atro- 
phy. These  correspond  very  closely  with  the  three  stages  described 
by  Frerichs. 

2.  The  Waxy  i^orm.— This  also  has  three  stages:  (1)  That  of 
simple  degeneration  of  the  vessels;  (2)  That  in  which  a  secondary 
alteration  of  the  tubes  is  superadded;  and  (3)  That  of  atrophy. 

In  the  first  stage,  the  kidney  is  of  normal  size,  the  tubes  are  im- 


8  DELAPIELD — DISEASES   OP  THE  KIDNEYS. 

altered;  only  tlie  Malpighian  bodies  and  small  arteries  have  under- 
gone waxy  degeneration. 

In  the  second  stage,  tlie  kidney  is  enlarged,  the  cortex  thick  and 
white,  with  Malpighian  bodies  and  small  vessels  waxy;  the  tubes 
contain  hyaline  casts;  their  epithelium  is  swollen;  their  basement 
membrane  may  be  waxy. 

In  the  third  stage,  the  kidney  is  small.  The  surface  is  rough, 
granular,  and  pale.  The  tubular  structures  are  swollen.  The  tufts 
and  vessels  are  waxy.  A  few  tubes  are  distended,  most  are  collapsed, 
and  are  represented  only  by  fibrous  tissues. 

3.  The  Cirrhotic,  or  Coyitracting  Form. — This  consists  of  an  hyper- 
trophy of  the  connective  tissue  of  the  organ,  and  a  consequent  atro- 
phy of  all  the  other  structures. 

There  is  at  first  little  diminution  in  the  size  of  the  organ,  but  the 
capsule  is  thickened  and  adherent,  and  the  surface  is  rough  and  gran- 
ular. The  color  is  pale  and  reddish.  The  arteries  are  fjrominent, 
their  walls  thickened,  and  their  cavities  often  dilated.  On  the  surface, 
and  in  the  substance,  cysts  are  often  seen.  Some  are  produced  by 
dilatation  of  the  Malpighian  capsules,  some  by  dilatation  of  the  tubes, 
some  by  a  morbid  growth  of  epithelial  elements.  The  tubes  are  com- 
pressed and  atrophied  by  the  new  fibrous  tissue.  They  contain  little 
opaque  material,  but  often  hyaline  matter.  Sometimes  urate  of  soda 
is  found  in  the  stroma  and  tubes  of  the  pyramids.  The  disease  is  a 
non-inflammatory  increase  of  connective  tissue. 

Both  the  waxy  and  contracting  forms  may  be  secondarily  affected 
with  the  inflammatory  disease. 

4.  Simple  Fatty  Degeneration. — The  kidneys  are  of  about  the  nor- 
mal size.  The  surface  is  smooth,  the  capsule  not  adherent.  Their 
texture  is  soft,  the  cortex  is  pale  and  mottled,  with  sebaceous-looking 
deposits.     The  epithelium  of  the  tubes  is  fatty. 

Dickinson  describes  tubal  nephritis,  granular  degeneration,  and 
depurative  infiltration : 

1.  Acute  Tubal  Nephritis. — This,  the  nephritis  of  scarlet  fever  and 
of  exposure  to  cold,  is  described  in  very  much  the  same  terms  as  the 
acute  desquamative  nephritis  of  Johnson. 

2.  Chronic  Tubal  Nephritis. — The  kidney  is  large,  the  cortex  of 
an  opaque  white  or  buff-color,  the  pyramids  pink.  The  surface  is 
smooth,  the  capsule  not  adherent.  The  convoluted  tubes  are  dis- 
tended with  granular  and  fatty  epithelium  and  with  fibrinous  exuda- 
tion. The  straight  tubes  are  packed  with  the  products  of  epithelial 
growth,  while  others  contain  transparent  fibrin.  The  tubes  are  not 
changed,  save  as  regards  their  contents.  The  Malpighian  bodies  are 
normal  or  somewhat  dilated.     There  is  no  increase  of  intertubular 


CIASSEFICATION   OP  DISEASES   OF  THE   KIDXEY.  9 

tissue.     These  kidneys  remain  large  and  smootli  to  the  last,  unless 
complicated  with  the  depurative  change. 

Sometimes  the  cortex  is  sprinkled  with  white,  sharply  defined 
specks,  like  bits  of  bran.  This  change  is  characteristic  of  a  great 
amount  of  fatty  change  in  the  accumulated  epithelium. 

3.  Granular  Degeneration. — The  kidneys  may  be  of  normal  or  even 
increased  size,  but  are  usually  small.  The  capsule  is  adherent.  The 
surface  is  irregular  and  covered  with  little  rounded  nodules.  The 
cortex  is  thin.  Cysts  are  often  found  in  the  cortex  and  cones.  There 
is  an  increase  of  fibrous  tissue  around  the  Malpighian  bodies  and  ves- 
sels, and  beneath  the  capsule  and  deeper  in  the  cortex.  The  cortical 
tubes  are  atrophied  or  dilated,  but  many  tubes  may  remain  un- 
changed. The  tubes  may  be  filled  with  epithelium,  or  with  trans- 
parent, fibrinous  material.  In  the  majority  of  cases  the  epithelium 
is  "exactly  such  as  is  found  in  normal  kidneys.  When  changed,  it  is 
by  an  alteration  in  its  regularity  of  form,  becoming  somewhat  angu- 
lar, as  if  cramped  in  growing  space.  The  circulation  through  the 
blood-vessels  is  much  obstructed.  The  formation  of  cysts  is  due  to 
dilatation  of  the  tubes  or  of  the  Malpighian  capsules. 

4.  Depuraiive  Infltration. — The  kidney  is  at  first  of  normal  size, 
pale,  and  its  surface  smooth.  The  only  change  is  in  the  Malpighian 
tufts,  which  react  with  iodine.  As  the  disease  goes  on,  the  kidney 
becomes  larger  and  its  capsule  adherent.  The  cortex  is  of  a  pale, 
opaque  fawn  color,  or  has  a  pinkish  or  gray  translucency.  After- 
ward the  kidney  atrophies  and  its  surface  becomes  nodulated.  There 
may  be  small  cysts.  In  cases  of  long  standing,  almost  the  entire 
organ  gives  the  characteristic  reaction  with  iodine.  The-first  change 
is  the  infiltration  of  the  Malpighian  bodies  and  vessels.  Afterward 
new  fibrous  tissue  is  formed  between  the  tubes,  the  epithelium  degen- 
erates, the  tubes  are  dilated  and  contain  fibrinous  casts. 

It  will  be  seen  that  the  name  of  "  depurative  infiltration"  is  given 
to  the  same  form  of  kidney  disease  which  is  called  by  others  waxy  or 
amyloid. 

Klebs  describes : 

1.  Diffuse  Granular  Degeneration  of  the  Djjithelium. — This  condi- 
tion is  found  by  itself,  and  in  connection  with  lesions  in  the  intersti- 
tial tissue.  By  itself,  it  occurs  with  pyaemia,  phthisis,  rheumatism, 
typhoid  and  typhus  fevers,  the  malarial  fevers,  the  acute  exanthemata, 
extensive  burns,  poisoning  with  j)hosphorus  and  the  mineral  acids. 
During  life  the  urine  may  contain  granular  casts  and  albumin.  The 
kidney  is  somewhat  enlarged,  the  cortex  grayish-yellow,  the  pyramids 
bluish-red.  There  may  be  little  extravasations  of  blood  in  the  con- 
voluted tubes.     The  epithelium  of  the  tubes  is  granular  and  may 


10  DELAPIELD — DISEASES   OF  THE  KIDNEYS. 

distend  tliem.  Tlie  tubes  may  contain  casts.  Tliese  clianges  are 
most  frequent  in  tlie  convoluted  tubes,  but  are  sometimes  confined  to 
tlie  straight  tubes  of  tb.e  pyramids.  The  entire  process  is  a  degener- 
ative and  not  an  inflammatory  one. 

2.  Cyanotic  Induration  of  the  Kidneys. — Tbis  condition  is  produced 
by  any  long-continued  obstruction  to  the  escape  of  venous  blood  from 
the  kidneys,  most  frequently  by  heart  disease.  The  kidneys  are  in- 
creased in  size,  the  surface  is  smooth,  the  capsule  not  adherent.  The 
organ  is  hard,  the  cortex  and  pyramids  are  congested  and  of  a  dark- 
red  color.  The  epithelium  of  the  tubes  is  not  altered.  The  interstitial 
tissue  is  harder,  but  not  increased  in  amount.  The  continued  conges- 
tion may,  after  a  time,  produce  further  changes.  The  epithelium  of 
the  convoluted  tubes  may  undergo  granular  degeneration,  and  the 
cortex  becomes  paler.  Or  there  may  be  an  increase  of  interstitial 
tissue,  and  the  surface  becomes  nodular. 

3.  Interstitial  Nephritis. — This  has  two  stages:  (a)  That  of  cell-in- 
filtration ;   (5)  That  of  atrophy. 

ict)  The  Stage  of  Cellular  Infiltration  of  the  Interstitial  Connec- 
tive Tissue. — The  kidney  is  increased  in  size.  The  surface  is 
smooth,  the  capsule  not  adherent.  The  cortex  is  of  a  whitish  or  yel- 
lowish color,  the  pyramids  are  red.  In  the  cortex  the  tissue  between 
the  tubes  is  everywhere  increased  from  two  to  four  fold.  This  increase 
is  due  to  the  presence  of  lymphatic  elements  and  of  clear  serum.  There 
is  at  first  an  exudation  of  lymphatic  fluid,  which  dilates  the  lymphatic 
vessels  of  the  interstitial  tissue,  and  is  accompanied  by  an  emigration 
of  white  blood-globules,  which  finally  fill  all  the  spaces  in  the  inter- 
stitial tissue.  The  epithelium  of  the  convoluted  tubes  undergoes 
granular  degeneration  in  consequence  of  its  disturbed  nutrition. 
The  increased  pressure  of  blood  causes  an  exudation  of  the  elements 
of  the  blood  from  the  Malpighian  tufts,  namely,  fibrinogenic  material 
which  coagulates  in  the  tubes,  albumin,  and  red  blood-globules. 
The  lymphatic  cells  perforate  the  basement  membrane  of  the  tubes, 
and  become  adherent  to  the  fibrinous  cysts. 

(6)  The  Stage  of  Atrophy. — The  preceding  stage  may  terminate 
in  resolution  and  recovery.  If  it  does  not,  it  is  succeeded  either  by 
a  hyperplasia  of  connective  tissue  or  by  granular  atrophy. 

If  there  is  a  hyperplasia  of  connective  tissue,  the  kidneys  are  of 
normal  size,  or  slightly  atrophied.  The  capsule  is  somewhat  adhe- 
rent. The  cortex  is  whitish,  yellowish,  or  mottled.  The  pyramids 
are  congested.  There  is  a  uniform  increase  of  connective  tissue  be- 
tween the  tubes.     The  tubes  are  unaltered  or  somewhat  narrowed. 

Granular  atrophy  is  more  common.  The  kidney  is  atrophied. 
The  capsule  is  very  adherent.     The  surface  is  uneven  and  nodular. 


CLASSIFICATION  OF  DISEASES  OP  THE  KIDNEY.  11 

The  change  of  the  lymphatic  cells  into  connective  tissue  is  accompa- 
nied by  fatty  degeneration  of  the  cells.  In  the  atrophied  spots  the 
tubes  and  glomeruli  become  imjjervious.  The  tubes  contain  hyaline 
casts.  The  basement  membrane  of  the  atrophied  tubes  becomes  thick 
and  fibrous.  The  glomeruli  are  atrophied,  their  capsules  thickened, 
their  vessels  obliterated.     The  larger  arteries  are  thickened. 

Glomerulo-nephritis. — Klebs  gives  this  name  to  a  form  of  disease 
which  he  has  observed  in  scarlatina  cases.  The  kidneys  are  of  me- 
dium size,  the  capsule  is  not  adherent,  the  surface  smooth,  the  paren- 
chyma congested.  There  are  no  changes  except  in  the  glomeruli. 
These  appear  as  opaque,  white  points.  On  minute  examination,  it 
is  found  that  there  are  large  numbers  of  small,  rounded  cells  about  the 
loops  of  the  Malpighian  tuft,  while  the  epithelium  of  the  capsule  is 
unaltered. 

Amyloid  degeneration  is  described  in  much  the  same  way  as  by 
other  authors. 

Bindfleisch  describes : 

1.  Acute  Parenchymatous  Nephritis. — In  the  milder  form  the  kid- 
ney is  of  normal  size,  the  surface  smooth,  the  cortex  of  a  yellowish- 
gray  color.  There  is  a  moderate  degree  of  cloudy  swelling  of  the 
epithelium  of  the  convoluted  tubes. 

In  the  severer  form  the  kidney  has  the  same  appearance,  but  is 
increased  in  size  and  the  cortex  is  thickened. 

Both  these  forms  occur  with  the  acute  exanthemata,  typhus 
fever,  pyaemia,  etc. 

2.  Diffuse  Inter stitinl  Nephritis. — This  corresponds  very  closely 
with  the  description  given  by  Klebs. 

He  states  that  the  disease  may  begin  as  a  parenchymatous  ne- 
phritis, and  afterward  become  interstitial,  but  that  the  two  forms  also 
occur  independently  of  each  other. 

Amyloid  degeneration  is  usually  accompanied  by  interstitial  ne- 
phritis. The  amyloid  degeneration  is  the  primary  change,  and  the 
nephritis  follows  it  as  a  secondary  lesion. 

Rosenstein  describes : 

1.  Chronic  Congestion  of  the  Kidney. — This  condition  is  described 
in  much  the  same  way  as  by  the  preceding  authors. 

2.  Catarrhal  Nephritis. — ^The  kidney  is  of  normal  size,  or  slightly 
enlarged ;  in  severe  cases  congested  and  mottled  with  small  ecchy- 
moses.  The  process  begins  at  the  apices  of  the  pyramids,  which  are 
at  first  congested,  afterward  pale.  After  a  time  we  find  the  pyramids 
divided  into  red  and  white  strias,  running  from  the  apex  to  the  base 
of  the  pyramids.  The  red  striae  are  the  portions  more  recently  con- 
gested ;  the  white  are  the  tubes  distended  by  an  increase  of  epithelium. 


12  DELAFIELD— DISEASES   OE  THE   KIDNEYS. 

The  urine  contains  a  little  albumin,  hyaline,  granular,  and  epithe- 
lial casts  and  blood-globules. 

The  symptoms  during  life  are  not  marked.  The  lesion  is  seldom 
primary.  It  may  follow  catarrhal  inflammation  of  the  urethra,  blad- 
der, or  ureters ;  the  use  of  cantharides,  copaiba,  or  cubebs ;  typhoid 
or  typhus  fever,  cholera,  etc. 

3.  Diffuse  Nephritis,  Parenchymatous  Nephritis,  BrigMs  Disease, 
Granular  Degeneration  of  the  Kidney. — This  form  has  three  stages. 

The  first  stage  is  that  of  hyperemia.  The  kidney  is  of  normal 
size,  or  enlarged,  congested,  and  red;  there  is  blood  in  the  tubes,  and 
the  epithelium  of  the  convoluted  tubes  is  swollen. 

The  second  stage  is  that  of  exudation.  The  kidney  is  enlarged, 
the  cortex  pale,  the  pyramids  red.  The  epithelium  of  the  convoluted 
tubes  is  swollen  and  granular.  The  tubes  are  dilated  and  contain 
casts.     There  is  usually  an  increase  of  cells  in  the  interstitial  tissue. 

The  third  stage  is  that  of  atrophy.  The  kidney  becomes  smaller, 
its  surface  nodular.  The  atrophy  may  take  place  without  any  change 
in  the  interstitial  tissue,  simply  as  a  result  of  the  destruction  of  the 
epithelium.  Usually,  however,  the  retraction  of  the  new  interstitial 
tissue  assists  in  producing  the  atrophy. 

The  epithelium  is  granular  or  fatty.  The  Malpighian  bodies  are 
atrophied,  their  capsules  thickened  and  surrounded  with  new  connec- 
tive tissue.  The  basement  membranes  of  the  tubes  are  thickened, 
and  are  accompanied  by  bands  of  connective  tissue.  The  intertubu- 
lar  capillaries  are  partly  dilated,  partly  small  and  fatty. 

The  atrophy  consists,  therefore,  in  a  suppression  of  the  function 
of  a  number  of  the  tubes,  with  obliteration  of  some  of  the  blood-ves- 
sels and  increase  of  the  interstitial  tissue. 

Either  process,  that  in  the  epithelium  or  that  in  the  connective 
tissue,  can  occur  separately,  but  they  are  usually  combined. 

4.  Amyloid  Degeneration.  — Kosenstein  describes  this  form  in  much 
the  same  way  as  other  authors.  He  regards  the  degeneration  of  the 
vessels  only  as  a  complication  of  the  parenchymatous  and  inter- 
stitial change. 

5.  The  Fatty  Kidney. — There  is  an  infiltration  of  the  ei)ithelium 
with  fat,  or  a  fatty  degeneration.  The  condition  is  described  in  the 
same  way  as  the  diffuse  granular  degeneration  of  Klebs. 

Weigert  divides  Bright' s  disease  into  parenchymatous  degenera- 
tion and  true  nephritis.  He  does  not  distinguish  between  interstitial 
and  parenchymatous  forms  of  nephritis,  but  believes  that  in  all  cases 
the  disease  begins  with  degeneration  of  the  epithelium,  which  is  fol- 
lowed by  inflammatory  interstitial  processes. 

Gull  and  Sutton  have  shown  very  clearly  the  frequency  with  which 


CLASSIFICATION  OF  DISEASES  OF  THE  KIDNEY.  13 

changes  in  the  arteries  and  capillaries — arterio-capillary  fibrosis — are 
associated  with  the  atrophic  form  of  Bright' s  disease;  and  that  these 
changes  in  the  arteries  and  capillaries  may  also  exist  and  give  symp- 
toms without  any  lesions  of  the  kidneys.  From  these  facts  they  have 
drawn  the  conclusion  that  this  form  of  Bright' s  disease  is  not, 
properly  speaking,  a  disease  of  the  kidneys,  but  rather  one  of  the 
arteries  and  capillaries. 

Bartels  uses  the  name  of  "  The  Diffuse  Diseases  of  the  Kidneys, " 
with  the  subdivisions  of  Hypersemia,  Ischsemia,  Acute  Parenchyma- 
tous Nephritis,  Chronic  Parenchymatous  Nephritis,  Eenal  Cirrhosis, 
and  Amyloid  Degeneration. 

Active  hypercemia  is,  he  says,  a  condition  which  arises  solely  as 
the  result  of  some  toxic  influence,  most  frequently  from  the  use  of 
cantharides.  Apparently  he  has  little  or  no  personal  experience  of 
the  anatomical  changes  found  in  the  kidneys. 

Passive  hypercemia  is  the  same  condition  as  that  called  also 
chronic  congestion  of  the  kidney,  and  cyanotic  induration  of  the 
kidney.  Its  most  important  form  is  that  due  to  valvular  lesions  of 
the  heart  and  to  certain  affections  of  the  lungs.  He  makes  no  new 
statements  concerning  the  pathological  changes. 

Ischoemia  is  the  condition  of  more  or  less  complete  stoppage  of  the 
arterial  blood-supply  to  the  kidneys,  occurring  independently  of  con- 
gestion of  the  nervous  system.  It  occurs  only  in  the  asphyxia  stage 
of  cholera. 

Acute  Parenchymatous  Nephritis. — Under  this  name  Bartels  in- 
cludes all  the  cases  of  acute  Bright' s  disease.  He  says  that  the 
only  essential  and  constant  microscopical  appearances  are  the  changes 
in  the  epithelium  of  the  tubes.  The  epithelial  ceUs  are  swollen  and 
cloudy,  they  are  infiltrated  with  granules  of  fat,  and  are  broken  down. 
To  these  changes  in  the  epithelium  are  frequently  added  a  swelling 
and  infiltration  of  the  stroma,  casts  in  the  tubes,  and  extravasations 
of  blood. 

Chronic  Parenchymatous  Nephritis. — This  may  follow  acute  paren- 
chymatous inflammation  or  may  begin  as  a  chronic  process.  The 
kidneys  are  large,  white,  and  smooth.  The  tubes  are  dilated ;  the 
epithelium  is  only  partly  preserved,  and  the  cells  which  remain  are 
large,  granular,  and  fatty.  In  many  i:)laces  the  epithelium  is  com- 
pletely gone  and  in  its  stead  the  tubes  are  entirely  filled  with  masses 
of  detritus  mixed  with  oil-globules ;  casts  are  found  in  many  of  the 
tubes.  The  stroma  is  thickened  by  fluid  exudation,  by  an  emigra- 
tion of  white  blood-cells,  and  by  a  growth  of  new  connective  tissue. 
The  small  arteries  and  Malpighian  tufts  are  often  the  seat  of  waxy 
degeneration. 


14  DELAFIELD — DISEASES  OF  THE  KIDNEYS. 

Benal  Cirrhosis. — The  kidney  is  very  much  diminished  in  size, 
especially  the  cortex.  This  diminution  in  size  is  due  to  the  wasting 
of  the  glandular  tissue,  while  at  the  same  time  there  is  an  extensive 
growth  of  new  fibrous  tissue.  The  change  in  the  kidney  is  due  to 
a  primary  growth  of  the  intertubular  connective  tissue,  and  this  leads 
to  the  dwindling  of  the  substance  of  the  gland,  a  wasting  preceded 
by  no  inflammatory  swelling  of  the  organ. 

To  Cohnheim  belongs  the  merit  of  drawing  attention  to  the  im- 
portance of  the  glomeruli  in  acute  nephritis,  and  to  the  changes  which 
are  found  in  them.  He  also  points  out  clearly  that  well-marked 
symptoms  of  acute  nephritis  may  exist  during  life,  although  no  struc- 
tural changes  are  found  in  the  kidneys  after  death. 

Langhans,  Nauwerck,  and  Friedlander  have  developed  still  further 
the  doctrine  of  glomerulo-nephritis,  and  have  described  in  detail  the 
lesions  found  in  the  glomeruli. 

Ziegler  describes : 

1.  Glomeruh-nepliritis,  occurring  either  by  itself  or  combined  with 
changes  in  the  epithelium  of  the  tubes  or  with  exudation  of  inflam- 
matory products  into  the  stroma. 

2.  Chronic  Parenchymatous  Nephritis. — The  common  feature  of  this 
form  of  nephritis  is  that  there  is  a  continuous  inflammatory  exudation 
from  the  blood-vessels,  and  that  changes  go  on  in  the  epithelium 
of  the  kidney. 

As  subdivisions  of  parenchymatous  nephritis  he  distinguishes : 
The  inflammatory,  fatty  kidney ; 
Chronic  hemorrhagic  nephritis; 
Chronic  glomerulo-nephritis. 

3.  Chronic  Indurative  Nep)hritis. — The  inflammation  leads  to  a  new 
growth  of  connective  tissue  in  the  stroma,  and  an  atrophy  of  the 
tubes  and  the  glomeruli. 

4.  The  Arteriosclerotic  Contracted  Kidney. — In  this  the  changes 
begin  in  the  walls  of  the  arteries ;  they  are  thickened,  their  lumen 
is  narrowed  or  obliterated.  As  a  result,  smaller  or  larger  numbers  of 
glomeruli  become  atrophied,  with  the  kidney  tissue  belonging  to 
them.     The  stroma  is  not  much  thickened. 

Cornil  remarks  that  the  expression  of  Bright' s  disease  applied  to 
the  kidney  has  nowadays  no  more  value  than  the  expression  of 
dyspepsia  applied  to  the  pathology  of  the  stomach  or  of  asystolie 
applied  to  the  pathology  of  the  heart.     He  distinguishes : 

1.  Granidar  alteration  of  the  renal  epithelium, — a  common  lesion 
found  in  different  forms  of  hyperemia,  especially  in  those  symptom- 
atic of  the  infectious  diseases. 

2.  Fatty  degeneration,  which  is  secondary  to  the  chronic  diseases. 


CLASSIFICATION  OF  DISEASES  OF  THE   KIDNEY.  15 

3.  Ghronic  congestion  of  the  kidney,  due  to  meclianical  disturbances 
of  the  circulation. 

4.  Diffuse  nephritis,  in  whicli  all  the  anatomical  elements  of  the 
tidney  are  involved. 

{d)  Acute  nephritis  with  predominance  of  congestive  and  inflam- 
matory phenomena. 

(6)  Acute  nephritis  with  predominance  of  diapedesis. 
(c)  Acute  nephritis  with  predominance  of  degenerative  lesions. 
{d)  Nephritis  with  predominance  of  the  lesions  of  the  glomeruli. 
(e)  Nephritis  with  predominance  of  lesions  of  the  ejjithelium. 
(/)  Nephritis  with  predominance  of  lesions  of  the  stroma. 

5.  Systematic  nephritis,  in  which  from  the  first  the  lesion  involves 
exclusively  one  of  the  elements  of  the  kidney. 

(a)  Epithelial  cirrhosis  of  the  kidney.  A  chronic  degeneration  of 
the  renal  epithelium  with  atrophy  of  certain  systems  of  tubes  and 
glomeruli. 

(6)  Vascular  cirrhosis — a  true  interstitial  inflammation  of  the 
kidney  with  endarteritis  of  the  renal  arteries. 

All  of  Cornil's  anatomical  descriptions  are  very  true  to  nature,  but 
his  classification  is  not  one  adapted  to  clinical  purposes. 

As  we  look  back  over  the  history  of  the  disease,  it  is  easy  to  rec- 
ognize the  points  of  difference  and  the  progress  which  has  been 
made. 

From  the  very  first  we  find  authors  looking  at  the  disease  from 
two  points  of  view :  that  of  the  symptoms  and  that  of  the  lesions. 
So  that,  while  some  regard  Bright's  disease  as  a  nephritis  with  its 
attendant  symptoms,  others  regard  it  as  a  disease  of  the  blood,  or  of 
the  arteries  and  capillaries,  with  which  a  nephritis  may  or  may  not 
be  associated. 

At  the  time  when  Frerichs  wrote,  it  was  customary  to  regard  a 
great  many  morbid  conditions  as  of  an  inflammatory  character,  and 
to  think  that  every  inflammation  went  regularly  through  three  stages. 
So  we  find  Frerichs  arranging  all  the  lesions  of  Bright's  disease  as 
belonging  to  the  stages  of  congestion,  exudation,  and  contraction  of 
a  nephritis,  and  teaching  that  all  the  forms  of  acute  and  chronic 
Bright's  disease  were  different  stages  of  one  and  the  same  morbid 
process. 

Then  we  find  in  England,  first  Johnson,  and  then  Dickinson,  re- 
ferring most  of  the  kidney  lesions  to  changes  in  the  epithelium  of  the 
tubes.  Here,  again,  it  soon  became  evident,  that  although  changes 
in  the  epithelium  exist  j^^nd  are  of  importance,  yet  Johnson  and  his 
school  had  taken  too  one-sided  a  view  of  the  subject. 

That  in  some  cases  of  Bright's  disease  there  is  waxy  degeneration 


16  DELAPIELD — DISEASES   OF  THE   KIDNEYS. 

of  the  walls  of  the  arteries  and  Malpigliian  tufts  was  early  recognized 
by  Eokitansky.  As  these  kidneys  have  been  more  studied,  it  has 
been  found  that  there  may  be : 

1.  Waxy  degeneration  of  the  arteries  and  glomeruli,  without  any 
change  in  the  other  parts  of  the  kidneys  or  any  disturbance  of  its 
functions. 

2.  Waxy  degeneration  of  the  arteries  and  tufts,  followed  by 
chronic  changes  in  the  rest  of  the  kidneys. 

3.  Waxy  degeneration  of  the  arteries  and  tufts,  forming  an  unim- 
portant part  of  a  chronic  nephritis. 

The  next  step  forward  was  the  recognition  by  Traube  of  the  con- 
dition of  chronic  congestion  of  the  kidney,  its  dependence  on  heart 
disease,  and  its  termination  in  changes  in  the  structure  of  the  kidney. 

Then  we  find  an  attempt  by  Grainger  Stewart  to  go  back  to  Fre- 
richs'  classification  of  an  inflammation  in  three  stages,  but  separating 
the  waxy  and  the  cirrhotic  kidneys. 

Among  English  writers  we  find  a  disposition  to  class  the  kidneys 
according  to  their  gross  appearance,  and  to  speak  of  the  large  white 
kidney  and  the  contracted  kidney,  and  to  regard  the  cirrhotic  kidney 
as  not  inflammatory.  In  England,  also,  we  find  especial  attention 
drawn  to  the  condition  of  the  arteries  and  capillaries  in  the  kidneys 
and  in  the  rest  of  the  body  as  a  cause  of  the  kidney  lesions  and  of  the 
symptoms. 

The  next  step  forward  was  the  recognition  of  the  changes  in  the 
glomeruli,  first  by  Klebs,  then  by  Cohnheim,  Eriedlander,  and  others. 

At  the  same  time  there  has  been  an  attempt,  especially  in  Ger- 
many, to  class  together  the  changes  in  the  epithelium,  the  exudation 
of  inflammatory  products,  and  the  formation  of  new  connective  tissue 
under  the  one  head  of  parenchymatous  inflammation,  teaching  that 
the  morbid  process  originates  in  the  epithelium,  and  that  the  other 
changes  are  secondary  to  this. 

Further  modifications  have  been  introduced  into  this  doctrine  of 
parenchymatous  nephritis  by  the  contention  that  changes  in  the 
epithelium  alone  are  not  of  inflammatory,  but  of  degenerative,  nature. 
Incidentally  Cohnheim  brings  out  well  the  important  point  that  with 
well-marked  changes  in  the  urine  and  constitutional  symptoms  we 
may  find  no  structural  changes  in  the  kidneys ;  in  other  words,  that 
the  morbid  changes  in  these  kidneys  must  have  been  confined  to  the 
blood-vessels. 

With  Ziegler,  Cornil,  and  others  have  come  in  an  improved  tech- 
nique and  an  exact  study  of  the  changes  in  the  kidney,  which  have 
given  us  a  much  more  satisfactory  knowledge  of  the  lesions. 

Although  so  much  has  been  done  in  the  study  of  the  lesions  of 


CLASSIFICATION  OF  DISEASES  OF  THE  KIDNEY.  17 

Bright's  disease,  it  must  be  confessed  that  the  ideas  of  the  profes- 
sion in  general  concerning  it  are  still  somewhat  crude. 

As  regards  acute  Bright's  disease,  we  often  find  the  belief: 

That  the  kidneys  are  large,  and  either  white  or  congested ;  that 
the  chief  change  is  in  the  epithelium  of  the  tubes,  which  is  swollen 
and  detached  and  blocks  up  the  tubes ;  that  there  is  some  change  in 
the  glomeruli  which  allows  albumin  to  pass  through  the  walls  of  the 
capillaries ;  that  the  patients  pass  too  little  urine ;  that  in  consequence 
of  this  diminished  production  of  urine  there  may  be  developed  dropsy 
or  cerebral  symptoms ;  that  the  chief  object  of  treatment  is  to  make 
them  pass  more  urine,  or,  failing  this,  to  purge  or  sweat  them. 

As  regards  chronic  Bright's  disease,  it  is  generally  believed  that 
there  are  two  principal  forms :  one,  in  which  the  kidney  is  more  or 
less  large  and  white,  while  during  life  there  is  dropsy,  and  much  al- 
bumin in  the  urine;  and  one  in  which  the  kidney  is  more  or  less 
contracted  and  red,  and  there  is  little  or  no  albumin  in  the  urine, 
and  little  or  no  dropsy. 

It  has  become  evident  to  many  careful  observers  that  there  is  a 
group  of  persons  who  are  more  liable  than  are  others  to  chronic  pro- 
ductive inflammation  in  different  parts  of  the  body.  It  may  be  the 
lungs,  or  the  heart,  or  the  arteries,  or  the  liver,  or  the  kidneys  that 
are  affected;  and  either  one  or  several  of  these  organs  are  involved 
at  the  same  time. 

The  liability  is  most  common  after  forty-five  years  of  age,  but  is 
by  no  means  infrequent  in  younger  persons.  Unquestionably  many 
of  these  persons  are  gouty ;  in  some  there  is  a  history  of  chronic  alco- 
holism ;  in  some  there  is  an  hereditary  history ;  many  of  them  suffer 
from  disturbances  of  digestion;  many  of  them  have  habitually  an  ex- 
cess of  urates,  or  oxalates,  or  occasional  sugar,  or  albumin  in  the 
urine. 

So  great  is  the  number  of  these  cases,  and  so  constantly  are  these 
persons  under  our  observation,  that  it  is  often  not  difficult  to  recog- 
nize that  an  individual  belongs  to  this  group  before  he  has  developed 
any  one  of  the  characteristic  inflammations.  We  can  predict  before- 
hand that  a  given  individual  will,  at  some  time,  develop  emphysema, 
or  chronic  endocarditis,  or  endarteritis,  or  cirrhosis  of  the  liver,  or 
chronic  nephritis. 

Curiously  enough  it  has  occurred  to  some  very  intelligent  physi- 
cians that  persons  in  this  group  are  really  all  suffering  from  the  same 
disease,  and  that  they  develop  the  characteristic  lesions  as  the  result 
of  the  disease.  They  jjropose  to  call  this  disease  Bright's  disease. 
According  to  this  view  a  person  can  have  Bright's  disease  while  the 

kidneys   are  still  normal.     In  this  way  have  come  in  the  terms  of 
Vol.  I.— 3 


18  DELAFIELD — DISEASES   OE  THE  KIDNEYS. 

"renal  inadequacy"  and  of  the  " pre-albuminuric  stage  of  Briglit's 
disease." 

There  can  be  no  question  that  this  group  of  cases  is  a  very  im- 
portant one,  and  it  is  quite  true  that  most  of  them  do  have  disease 
of  the  kidneys  before  they  die.  I  do  not  know  of  any  good  name  to 
designate  all  the  cases  of  this  kind,  but  I  do  not  think  we  have  any 
right  to  say  that  they  are  all  examples  of  one  disease.  Much  more 
probable  is  it  that  they  all  exhibit  the  effects  of  heredity,  environ- 
ment, and  mode  of  life. 

There  is  a  well-marked  disposition  on  the  part  of  some  authors  to 
include  cases  of  chronic  inflammation  of  the  arteries  under  the  name 
of  Bright's  disease.  This  view  of  the  matter  is  clearly  stated  by 
Mahomed  in  Guy's  Hospital  reports  for  1880. 

He  says :  "  The  object  of  this  paper  is  to  prove  that  in  the  earlier 
stages,  and  in  most  cases  even  to  their  final  stage,  the  urine  of  what  is 
generally  known  as  chronic  Bright's  disease  with  red  granular  kid- 
ney is  most  commonly  perfectly  normal.  More  than  this,  its  object 
is  to  prove,  either  that  chronic  Bright's  disease  is  not  a  renal  disease, 
although  it  frequently  gives  rise  to  a  renal  affection,  or  else  that 
another  disease  must  be  recognized  which  constantly  precedes  and 
prepares  the  way  for  Bright's  disease,  which  ma}^  be  called  arterio- 
capillary  fibrosis,  or  any  other  name  that  may  be  preferred  to  it. " 

The  cases  which  Mahomed  narrates  in  his  paper  seem  to  be  cases 
of  chronic  arteritis,  with  more  or  less  complicating  nephritis. 

In  the  present  state  of  our  knowledge  it  is  wiser  to  put  aside  the 
name  of  Bright's  disease  and  the  ideas  connected  with  it,  and  look 
for  a  classification  of  kidney  diseases  which  will  be  of  practical  clini- 
cal use  and  anatomically  correct.  There  seem  to  be  three  ways  in 
which  we  can  classify  kidney  diseases :  according  to  their  causes,  ac- 
cording to  the  part  of  the  kidney  involved,  or  according  to  the  nature 
of  the  morbid  process. 

To  classify  kidney  diseases  according  to  their  causes  is,  in  the  pres- 
ent state  of  our  knowledge,  simply  impossible.  If,  for  example,  we 
try  to  make  a  class  of  the  kidney  diseases  caused  by  scarlet  fever,  we 
find  that  the  poison  of  this  disease  produces  three  kidney  lesions 
which  differ  from  each  other  clinically  and  anatomically.  On  the 
other  hand  one  well-marked  form  of  acute  nephritis  is  caused  by  scar- 
let fever,  by  diphtheria,  by  pregnancy,  and  occurs  without  discover- 
able cause.  That  all  forms  of  nephritis  are  caused  by  irritating  sub- 
stances in  the  blood  is  very  probable ;  that  different  quantities  of  the 
same  poison  can  produce  different  forms  of  inflammation  has  been 
demonstrated,  but  we  are  still  very  far  from  being  able  to  construct 
a  classification  based  on  causes. 


CLASSIFICATION  OP  DISEASES  OP  THE  KIDNEY.  19 

To  classify  kidney  diseases  according  to  tlie  part  of  tlie  kidney 
principally  involved  is  very  natural  and  not  at  all  difficult.  There 
can  be  no  question  that  disease  of  the  epithelium,  of  the  glomeruli,  of 
the  stroma,  or  of  the  arteries  decidedly  jDredominates  in  different  sets 
of  kidneys.  A  classification  on  this  basis  is  anatomically  correct. 
But  when  we  try  to  use  this  classification  for  clinical  purposes  it  does 
not  answer.  The  history  which  I  have  already  given  of  anatomical 
classifications  shows  this  only  too  jjlainly.  A  classification  according 
to  the  nature  of  the  morbid  process  is  altogether  the  most  promising. 
There  are  three  morbid  processes  which  occur  in  nearly  every  part  of 
the  body,  which  produce  definite  anatomical  changes,  cause  regular 
clinical  symptoms,  and  call  for  appropriate  methods  of  treatment. 
These  morbid  processes  are  congestion,  degeneration,  and  inflam- 
mation. 

Congestion,  whether  acute  or  chronic,  produces  an  accumulation  of 
blood  in  the  veins  and  capillaries  of  the  part  affected,  causes  local 
symptoms  and  disturbances  of  function,  and  is  to  be  relieved  by 
means  addressed  to  the  circulation  of  the  blood. 

Degeneration,  whether  acute  or  chronic,  produces  changes  more  or 
less  profound  in  the  parts  affected ;  is  regularly  caused  by  poisons,  by 
disturbances  of  circulation,  and  by  other  diseases ;  produces  distur- 
bances of  function  according  to  its  severity ;  may  be  itseK  a  cause  of 
inflammation,  and  can  be  but  little  affected  by  treatment. 

Inflammation  is  attended  with  three  essential  features,  which  may 
occur  separately  or  together :  an  escape  of  the  elements  of  the  blood 
from  the  vessels,  a  formation  of  new  tissue,  and  a  death  of  tissue. 
So  we  speak  of  exudative,  productive,  and  necrotic  inflammations. 

(a)  Exudative  inflammation  is  of  short  duration,  leaves  behind  it 
no  permanent  changes  in  the  parts  affected,  is  sometimes  accompa- 
nied by  the  growth  of  pathogenic  bacteria,  and  can  be  favorably 
affected  by  treatment. 

(&)  Productive  inflammation  runs  an  acute,  subacute,  or  chronic 
course.  It  effects  permanent  changes  in  the  inflamed  parts.  Its 
acute  forms  are  very  apt  to  become  chronic.  There  is  much  variety 
as  to  the  relative  quantity  of  exudation  and  of  new  tissue.  Patho- 
genic micro-organisms  may  be  present. 

(c)  Necrotic  inflammation  is  characterized  by  the  addition  of 
death  of  tissue  to  an  inflammation  of  either  exudative  or  productive 
type.    It  is  always  accompanied  by  the  growth  of  pathogenic  bacteria. 

Applying  this  principle  of  classification  to  the  kidneys  we  can  dis- 
tinguish : 

1,  Acute  congestion  of  the  kidney. 

2.  Chronic  congestion  of  the  kidney. 


20  DELAPIELD — DISEASES  OP  THE   KIDNEYS. 

3.  Acute  degeneration  of  the  kidne3^ 

4.  Chronic  degeneration  of  the  kidney. 

5.  Acute  exudative  nephritis. 

6.  Acute  productive  nephritis. 

7.  Chronic  nephritis  with  exudation. 

8.  Chronic  nephritis  without  exudation. 

9.  Suppurative  nephritis. 
10.  Tubercular  nephritis. 


The  Urine. 

Quantity. 

In  healthy  adults  consuming  the  ordinary  quantities  of  fluids  and 
solids  the  daily  discharge  of  urine  is  1,250  cc,  or  50  fluid  ounces,  or 
3  pints.  This  quantity  is  liable  to  a  considerable  amount  of  variation 
according  to  the  quantity  of  fluid  taken  and  the  amount  of  perspira- 
tion. 

Complete  occlusion  of  the  pelves  of  the  kidneys  or  of  their  ureters 
leads  to  complete  suppression  of  urine.  It  is  not  that  urine  is  formed 
and  cannot  escape  on  account  of  the  occlusions,  but  that  the  kidneys 
cease  to  perform  their  functions.  Suppression  of  urine  is  always 
fatal,  but  yet  can  be  borne  for  a  number  of  days  almost  without  symp- 
toms. Sooner  or  later,  however,  prostration,  delirium,  stupor,  and 
the  typhoid  state  are  developed. 

Severe  injuries  and  surgical  operations,  especially  those  on  the 
urethra  and  bladder,  may  be  followed  by  a  suppression  of  urine  which 
is  often  fatal.  It  is  probable  that  this  supj)ressiou  is  due  to  an  acute 
congestion  of  the  kidneys.  Any  disturbance  of  the  circulation  which 
produces  either  acute  or  chronic  congestion  of  the  kidneys  regularly 
diminishes  the  quantity  of  urine.  So  we  find  that  in  acute  and 
chronic  congestion  of  the  kidney,  in  acute  nephritis,  in  the  exacerba- 
tions of  chronic  nephritis,  and  in  attacks  of  contraction  of  the  arteries 
the  quantity  of  urine  is  notably  diminished. 

When  the  body  temperature  is  considerably  higher  than  the  nor- 
mal the  urine  is  diminished  in  quantity. 

In  saccharine  diabetes  patients  pass  very  large  quantities  of  urine, 
the  kidneys  being  apparently  excited  to  increased  activity  by  changes 
in  the  composition  of  the  blood.  In  cases  of  insipid"  diabetes  the 
quantity  of  urine  of  low  specific  gravity  is  large,  but  it  is  not  deter- 
mined why  this  increase  takes  place. 

In  the  slow  forms  of  chronic  nephritis,  whether  with  or  without 
exudation,  it  is  the  rule  to  have  increased  quantities  of  urine  of  low 


THE  URINE.  21 

Specific  gravity,  the  quantity  being  especially  large  and  tlie  specific 
gravity  very  low  if  the  vessels  are  the  seat  of  waxy  degeneration.  But 
this  increased  production  of  urine  may  at  any  time  be  checked  by 
changes  in  the  heart's  action,  by  contraction  of  the  arteries,  or  by  an 
exacerbation  of  the  nephritis. 

Speoieic  Gravity. 

The  determination  of  the  specific  gravity  of  the  urine  gives  us  the 
relative  quantity  of  its  solid  and  fluid  constituents.  To  obtain  prac- 
tical information  on  this  point  it  is  necessary  to  examine  the  urine 
passed  at  difi^erent  times  in  the  day  on  a  number  of  days.  In  healthy 
persons  and  under  ordinary  conditions  the  specific  gravity  ought  not 
to  vary  much  from  1.020.  It  seems  to  be  generally  agreed  that  the 
solid  portions  of  the  urine  are  excreted  by  the  epithelium  of  the  con- 
voluted tubes  and  the  fluid  portions  filtered  through  the  Malpighian 
bodies.  We  would  expect,  therefore,  that  a  diminution  in  the  specific 
gravity  would  be  caused  by  changes  in  the  renal  epithelium,  and  a 
diminution  in  the  quantity  of  the  urine  by  atrophy  of  the  Malpighian 
bodies.  As  a  matter  of  fact  the  kidneys  behave  differently.  When 
the  morbid  changes  are  confined  to  the  epithelium,  as  in  acute  and 
chronic  degeneration,  the  specific  gravity  is  not  lowered;  when  the 
Malpighian  bodies  are  atrophied  in  chronic  nephritis  the  quantity  of 
urine  is  not  necessarily  diminished.  A  persistent  low  specific  gravity 
means  a  chronic  nephritis  with  a  large  production  of  new  interstitial 
connective  tissue,  or  with  waxy  degeneration  of  the  blood-vessels ;  or 
it  means  insipid  diabetes.  In  chronic  nephritis  the  specific  gravity 
remains  low  even  if  the  quantity  of  urine  is  very  much  diminished. 
But  in  insipid  diabetes  the  specific  gravity  rises  as  the  urine  is  dimin- 
ished in  quantity. 

An  increase  in  the  specific  gravity  regularly  accompanies  saccha- 
rine diabetes  and  chronic  congestion  of  the  kidneys. 

Constituents,  Normal  and  Adventitious. 

Urea. — The  most  important  of  the  solid  constituents  of  the  urine 
is  urea,  of  which  a  healthy  adult  excretes  every  day  about  500  grains. 
While  the  specific  gravity  of  the  urine  gives  a  general  idea  of  the  rela- 
tive quantity  of  urea,  yet  there  are  sources  of  error.  It  is  best  to  get 
the  whole  daily  excretion  of  urea  for  several  days  by  the  hypobromite 
method.  The  principal  importance  of  this  is  in  determining  the 
prognosis  of  cases  of  chronic  nephritis.  When  the  daily  excretion 
of  urea  is  much  below  the  normal  the  prognosis  is  bad,  although  the 
patients  may  seem  to  be  doing  well. 


22  DELAPIEU) — DISEASES   OF  THE  KIDNEYS. 

Urates,  Oxalates,  and  Phosphates. — Tlie  presence  of  an  excess  of 
uric  acid,  of  tlie  urates,  of  oxalate  of  lime,  and  of  the  phosphates  is 
of  importance,  not  because  it  indicates  disease  or  disturbance  of 
functions  of  the  kidneys,  but  because  it  shows  disordered  digestion 
and  an  abnormal  condition  of  the  blood.  There  are  many  cases  of 
kidney  disease  in  which  the  treatment  of  these  disturbances  is  of  the  • 
greatest  importance. 

Blood.  — Hsematuria  is  an  evidence  of  bleeding  from  some  part  of 
the  genito-urinary  tract.  So  far  as  the  Mdneys  are  concerned  the 
blood  comes  from  their  pelves,  or  from  the  kidneys  themselves.  Bleed- 
ing from  the  pelvis  occurs  with  pyelitis,  with  calculi  in  the  pelvis,  and 
with  new  growths  of  the  pelvis.  Bleeding  from  the  kidney  itself  is 
found  with  acute  nephritis,  with  exacerbations  of  chronic  nephritis, 
with  tubercular  nephritis,  with  the  hemorrhagic  forms  of  the  infec- 
tious diseases,  and  with  malignant  growths. 

Hoimoglohinuria. — There  are  morbid  conditions  in  which  a  con- 
siderable number  of  red  blood  cells  are  suddenly  killed  and  the 
coloring-matter  set  free  in  the  blood.  This  is  followed  by  a  dis- 
charge of  this  coloring-matter,  with  a  considerable  transudation  of 
blood  serum  from  the  kidneys,  in  the  urine.  We  find  then  a  good 
deal  of  albumin  and  of  red  coloring-matter  in  the  urine,  but  no  red 
blood  cells. 

Casts. — There  has  been  some  difference  of  opinion  as  to  the  mode 
of  formation  of  the  little  cylindrical  bodies  which  are  found  in  the  urine 
and  in  the  kidney  tubules.  The  question  has  been  whether  they  are 
all  formed  of  substances  coagulated  from  the  blood  plasma,  or  whether 
some  are  formed  of  substances  derived  from  the  renal  epithelium. 
Certainly  most  of  them  are  formed  from  the  blood  plasma.  They  are 
composed  of  a  transparent,  homogeneous  matter  with  which  may  be 
mixed  renal  epithelium,  white  and  red  blood-cells,  and  the  granular 
matter,  fat,  and  nuclei  derived  from  degenerated  epithelium.  The 
presence  of  casts  in  the  urine  means,  therefore,  that  there  has  been  an 
exudation  of  blood  serum  into  the  kidney  tubules  and  more  or  less  de- 
generation of  the  renal  epithelium.  The  number  of  casts  in  the  urine 
is  usually  an  indication  of  the  number  formed  in  the  kidneys,  but  not 
always ;  we  may  find  but  few  casts  in  the  urine  during  life  and  yet 
after  death  the  kidneys  are  seen  to  contain  a  large  number.  Albumin 
and  casts  are  usually  present  in  proportionate  quantities :  if  there  is 
much  albumin  there  are  generally  many  casts,  but  albumin  may  be 
present  in  large  quantities  with  very  few  casts.  The  centrifugal  ma- 
chines which  are  now  in  use  are  of  great  assistance  in  looking  for 
casts. 

Any  one  who  wishes  to  understand  casts  and  their  mode  of  forma- 


DEOPSY.  23 

tion  must  look  at  tliem  in  kidney  sections,  as  well  as  in  tlie  urine. 
It  seems  hardly  necessary  to  warn  against  confounding  cylindrical 
strings  of  mucus  formed  in  the  bladder,  often  having  crystals  im- 
bedded in  them,  with  casts  formed  in  the  kidney  tubules,  but  the 
mistake  is  sometimes  made. 

Hyaline  casts  in  small  numbers,  like  albumin  in  small  quantities, 
are  occasionally  present  without  disease  of  the  kidneys. 

Acute  congestion  of  the  kidneys  often  gives  hyaline  casts,  some- 
times granular  and  nucleated  casts. 

Chronic  congestion  gives  a  few  hyaline  casts. 

Acute  degeneration  gives  casts  according  to  its  severity — hyaline 
casts  only,  or  granular  and  nucleated  casts,  or  epithelial  and  blood 
casts. 

Chronic  degeneration  gives  only  a  few  hyaline  casts,  or  none 
at  all. 

Acute  exudative  and  acute  diffuse  nephritis  give  many  casts  of 
every  kind. 

Chronic  nephritis  with  exudation  gives  many  casts  of  all  kinds, 
their  number  being  much  increased  when  there  is  an  exacerbation 
of  the  nephritis. 

Chronic  nephritis  without  exudation  gives  a»few  hyaline  casts  or 
none  at  all. 

Albumin. — (See  page  26.) 

Dropsy. 

The  association  of  dropsy  with  kidney  disease  is  of  such  frequent 
occurrence  that  it  is  often  difficult  to  convince  both  patients  and  phy- 
sicians that  "Bright's  disease"  can  exist  when  dropsy  is  absent. 

If  we  go  through  the  list  of  diseases  of  the  kidney  we  find  that 
their  association  with  dropsy  is  as  follows : 

Acute  congestion  of  the  kidney — no  dropsy. 

Chronic  congestion  of  the  hidney — dropsy  according  to  the  condition 
of  the  heart. 

Acute  and  chronic  degeneration  of  the  kidney — no  dropsy. 

Acute  exudative  nephritis- — subcutaneous  dropsy,  most  frequent 
with  nephritis  caused  by  scarlet  fever,  or  by  exposure  to  cold.  A 
similar  subcutaneous  oedema  can  be  produced  by  scarlet  fever  or  by 
exposure  to  cold  without  nephritis. 

Acute  productive  (or  diffuse)  nephritis — both  subcutaneous  dropsy 
and  dropsy  of  the  serous  cavities. 

Chronic  nephritis  with  exudation — dropsy  of  the  subcutaneous  con- 
nective tissue  and  of  the  serous  cavities  in  nearly  every  case. 


24  DELAPIELD — DISEASES   OF  THE   KIDNEYS. 

Chronic  nepliritis  ivitliout  exudation — no  dropsy  until  late  in  the 
disease  unless  from  complicating  lesions. 

Suppression  of  urine  from  obstruction  of  the  ureters — no  dropsy. 

The  primitive  explanation  of  renal  dropsy  was  that  fluids  accu- 
mulated in  the  body  because  the  patient  passed  too  little  water.  This 
seemed  satisfactory  even  to  so  good  an  observer  as  Bartels.  It  has 
always  had  its  effect  on  therapeutics ;  the  rule  has  been,  if  a  patient 
has  dropsy  make  him  pass  more  urine.  This  explanation,  however, 
is  ill  constant  contradiction  with  clinical  experience. 

The  present  condition  of  our  knowledge  on  this  subject  may  be 
stated  somewhat  as  follows : 

1.  All  dropsies  are  due  to  an  increased  transudation  of  blood 
serum  from  the  capillaries  and  a  diminished  absorption  by  the 
lymphatics.  The  increased  transudation  is  the  more  important  part 
of  the  process. 

2.  Inflammatory  dropsies  (or  exudations)  and  passive  dropsies 
may  be  produced  in  one  of  two  ways : 

(a)  The  capillaries  act  as  filters.  The  blood  serum  within  them 
follows  the  laws  of  exosmosis.  Either  increased  pressure  or  a 
change  in  the  composition  of  the  serum  can  cause  an  increased  tran- 
sudation through  the  walls  of  the  capillaries. 

(&)  The  capillaries  with  their  endothelium  act  as  glands  and  se- 
crete serum.  Changes  in  the  composition  of  the  blood  or  irritating 
substances  in  the  surrounding  tissues  can  irritate  the  endothelium 
and  cause  increased  secretion. 

Following  these  rules  the  probable  explanations  of  renal  dropsies 
are: 

1.  In  acute  exudative  nephritis  the  dropsy  is  due  to  inflammatory 
changes  in  the  skin.  The  dropsy  is  regularly  confined  to  the  subcu- 
taneous connective  tissue,  and  is  especially  frequent  when  the  ne- 
phritis is  caused  by  scarlet  fever,  or  by  exposure  to  cold. 

2.  In  acute  productive  nephritis  and  in  chronic  nephritis  with  exu- 
dation the  dropsy  involves  both  the  subcutaneous  connective  tissue 
and  the  serous  cavities.  It  may  be  due  to  irritating  substances  in  the 
blood,  to  changes  in  the  composition  of  the  blood,  or  to  changes  in 
blood  pressure. 

3.  In  chronic  nephritis  without  exudation,  the  dropsy  which  comes 
on  late  in  the  disease  is  caused  by  changes  in  blood  pressure  due  to 
heart  failure. 

Scattered  through  medical  literature  are  reports  of  cases  of  gen- 
eral subcutaneous  dropsy  coming  on  suddenly,  lasting  for  a  short 
time,  without  any  evidence  of  renal  or  other  disease,  and  terminating 
in  recovery.     Traube  thinks  that  such  dropsies  are  due  to  a  disturb- 


DEOPSY. 


25 


ance  of  the  functions  of  tlie  skin  caused  by  exposure  to  the  weather, 
but  this  explanation  will  not  answer  for  all  the  cases.  In  some  pa- 
tients (Taylor,  Medical  Times  and  Gazette,  1871)  the  dropsy  was  pre- 
ceded by  a  well-marked  febrile  movement.  I  know  of  only  one  case 
of  this  kind  which  terminated  fatally.  It  is  reported  by  Wernicke 
{Deutsches  Archivfilr  klinische  Medicin,  YI. ,  622) .  The  patient,  a  girl 
twenty-two  years  old,  died  apparently  from  the  dropsy,  and  the 
autopsy  showed  no  lesion  to  account  for  the  symptoms.  The  follow- 
ing case  is  an  example  of  this  form  of  dropsy : 

Male,  26,  admitted  to  the  Roosevelt  Hospital  on  April  17th,  1884. 
He  had  been  perfectly  well  and  working  hard  until  two  months  ago. 
Then  he  began  to  have  cough,  mucous  sputa,  and  wheezing  breathing. 
One  month  ago  he  developed  general  subcutaneous  oedema ;  the  urine 
was  somewhat  diminished  in  quantity,  but  the  man  did  not  feel  sick. 
When  admitted  to  the  hospital  his  pulse  was  96,  temperature  98°  F., 
respiration  30.  There  was  very  marked  general  subcutaneous 
oedema.  The  skin  and  mucous  membranes  were  rather  pale,  but  the 
man  was  well-nourished  and  did  not  feel  at  all  sick.  A  soft  systolic 
murmur  could  be  heard  at  the  apex  and  base  of  the  heart ;  the  action 
of  the  heart  was  somewhat  intermittent  and  irregular.  The  dropsy 
increased  for  a  few  days  and  then  gradually  diminished.  The  record 
of  the  urine  was  as  follows : 


Date. 

Quantity    in 
Ounces. 

Albumin. 

Specific 
Gravity. 

Urea   in 
grains. 

April  19 

68 

42 

96 

150 

130 

84 

132 

136 

62 

44 

45 

None 
Trace 

None 

Trace 
None 

1024 
1012 
■    1022 
1010 
1026 
1008 
1014 
1012 
1014 
1016 
1014 
1016 

608 

"      20 

"      21 

340 

"      22 

351 

"      23 

280 

"      24 

479 

"      25 

672 

"      26 

858 

"      27 

410 

«      28 

394 

"      29 

"      30 

By  May  1st  the  dropsy  had  entirely  disappeared  and  the  man  was 
apparently  well. 

I  have  seen  a  number  of  hospital  i:)atients,  who  unquestionably 
had  kidney  disease,  but  who  had  attacks  of  subcutanous  oedema  after 
exposure,  aj^parently  not  connected  with  their  kidney  disease,  but 
caused  ])y  inflammation  of  the  skin. 

The  ordinary  treatment  of  dropsy  is  directed  to  the  removal  of 
tlie  serum  after  it  has  transuded  from  the  vessels.  We  try  to  got  rid 
of  the  dropsy  by  sweating,  l)y  diuresis,  or  by  purging.     It  is  evident 


26  DELAPIELD — DISEASES  OF  THE  KIDNEYS. 

that  a  much  more  satisfactory  treatment  would  be  to  prevent  the  tran- 
sudation. If  we  could  find  remedies  to  destroy  the  irritating  sub- 
stances in  the  blood  and  tissues  which  cause  the  blood  serum  to  tran- 
sude, we  would  be  able  to  prevent  the  dropsy  instead  of  having  to  get 
rid  of  it. 

Albuminuria. 

Since  the  time  of  Richard  Bright  the  presence  of  albumin  in  the 
urine  has  been  regarded  as  a  proof  of  kidney  disease  both  by  physi- 
cians and  by  the  laity.  And  in  spite  of  all  evidence  to  the  contrary 
this  is  still  the  popular  belief.  It  is  true  that  any  educated  physi- 
cian will  now  admit  that  albumin  may  be  absent  with  kidney  disease 
and  present  without  it,  but  this  admission  is  largely  theoretical.  In 
practice  the  old  belief  makes  itself  felt,  and  the  presence  of  albumin 
is  still  looked  for  as  the  main  evidence  of  disease  of  the  kidneys. 

The  general  belief  concerning  the  albumin  has  been  that  it  is  re- 
moved from  the  blood  by  the  kidneys  just  as  urea  or  sugar  is,  and  that 
if  large  quantities  of  it  are  removed  from  the  blood  the  compo- 
sition of  this  fluid  is  changed.  A  good  deal  of  pains  has  been  taken 
to  discover  why  it  is  that  diseased  kidneys  should  excrete  albumin. 

As  a  matter  of  fact  the  presence  of  serum  albumin  and  serum 
globulin  in  the  urine  means  that  the  blood  serum,  of  which  they  are 
constituents,  has  become  mixed  with  the  urine.  The  simplest  way 
in  which  this  can  happen  is  to  have  bleeding  from  the  bladder  or 
kidneys  so  that  the  blood  and  urine  are  mixed.  The  ordinary  way 
is  for  the  blood  serum  to  transude  from  the  kidney  capillaries  just  as 
it  does  from  capillaries  in  other  parts  of  the  body.  Albumin  in  the 
urine,  therefore,  means  the  same  thing  as  serum  in  a  serous  cavity, 
that  there  has  been  a  transudation  of  serum  from  the  vessels.  To 
keep  the  matter  clear  in  our  minds,  whenever  we  use  the  word  albu- 
minuria we  should  do  so  with  the  idea  that  it  is  a  popular  way  of  say- 
ing that  the  urine  has  blood  serum  mixed  with  it.  In  this  way  we 
will  think  of  the  kidney  as  we  do  of  other  parts  of  the  body — as  lia- 
ble to  exudations  of  serum  either  of  inflammatory  or  of  dropsical  char- 
acter. But,  just  as  in  the  serous  membranes  the  exudation  is  not  in 
the  membrane  but  in  its  cavity,  so  in  the  kidney  the  exudation  is  not 
into  the  parenchyma  but  into  the  tubules. 

The  CAUSES  of  albuminuria,  therefore,  are  the  same  as  the  causes 
of  dropsies  in  all  parts  of  the  body : 

1.  Changes  produced  hy  inflammation  in  the  walls  of  the  capillaries 
which  render  them  more  permeable.  In  this  way  are  produced  the 
albuminuria  of   both  forms  of  acute  nephritis,   that  of  the  severe 


ALBUMINUEIA.  27 

forms  of  acute  degeneration,  of  acute  congestion,  and  of  some  of  tlie 
cases  of  chronic  nephritis  with  exudation. 

2.  Changes  in  the  composition  of  the  Mood,  causing  either  increased 
filtration  or  increased  secretion  of  serum.  This  would  account  for 
the  albuminuria  of  anaemia,  of  puerperal  eclampsia  without  nephritis, 
of  the  mild  cases  of  acute  degeneration,  of  some  of  the  cases  of  acute 
and  chronic  nephritis  with  exudation. 

3.  Changes  in  the  blood  pressure.  This  would  be  the  probable 
cause  of  the  albuminuria  in  some  of  the  puerperal  cases,  in  chronic 
congestion,  in  some  of  the  cases  of  chronic  nephritis  with  exudation, 
and  in  chronic  nephritis  without  exudation. 

4.  Non-infiammatovy  changes  in  the  loalls  of  the  capillaries,  rendering 
them  more  permeable  to  the  escape  of  serum.  Such  changes  would 
account  for  the  albuminuria  which  is  found  without  inflammation  of 
the  kidneys,  changes  in  the  blood,  or  alterations  in  the  blood  pressure. 

The  significance  of  albumin  in  the  urine  depends,  therefore,  alto- 
gether upon  its  causation.  As  a  symptom  it  may  be  compared  to 
cough.  It  is  well  known  that,  while  cough  is  a  frequent  symptom  of 
disease  of  the  lungs,  yet  its  presence  does  not  tell  us  what  the  disease 
of  the  lungs  is,  nor  does.it  even  tell  us  that  there  is  necessarily  dis- 
ease of  the  lungs  at  all.  Albuminuria,  while  it  always  means  that 
the  capillaries  of  the  kidneys  .allow  the  blood  serum  to  transude 
through  their  walls,  does  not  tell  us  whether  the  causation  of  this 
transudation  resides  in  the  kidneys  or  outside  of  them.  The  study 
of  this  causation  is  practically  a  study  of  the  causes  of  dropsy. 

Albuminueia  without  Disease  op  the  Kidney. 

The  examination  of  the  urine  by  the  physicians  of  life  insurance 
companies,  and  by  other  physicians  who  have'  examined  this  excretion 
in  the  case  of  school  children,  of  soldiers,  and  of  other  groups  of 
persons,  has  brought  out  the  fact  that  albumin  is  present  in  the  urine 
in  many  persons  who  have  no  disease  of  the  kidneys.  These  persons 
can  be  arranged  in  the  following  groups : 

1.  Paroxysmal  or  Cyclic  Albuminuria. — The  characteristic  features 
of  this  form  of  albuminuria  are:  that  the  quantity  of  albumin  is 
large,  while  casts  are  few  or  absent ;  that  if  we  examine  the  urine  at 
regular  intervals  during  the  twenty-four  hours  we  find  a  regular  rise 
and  fall  in  the  quantity  of  albumin.  The  albumin  begins  to  appear 
soon  after  the  person  rises  in  the  morning,  increases  through  the  day, 
falls  after  he  goes  to  bed,  disappears  at  night,  and  reappears  the  next 
day.  This  regular  cycle  can  be  disturbed  by  changing  the  hours  of 
rest,  of  meals,  and  of  exercise.    The  rule  is  that  the  appearance  of  the 


28  DELAPIELD— DISEASES  OF  THE  KIDNEYS. 

albumin  is  favored  by  exercise  and  by  eating,  while  rest  in  bed  causes 
it  to  disappear.  There  seems  to  be  no  way  of  accounting  for  this 
form  of  albuminuria  except  by  supposing  that  there  are  changes  in 
the  composition  of  the  blood,  or  in  the  walls  of  the  renal  capillaries. 

The  persons  in  whom  this  form  of  albuminuria  is  present  are  regu- 
larly young  males,  who  also  suffer  from  more  or  less  disturbance  of 
the  general  health.  The  patients  suffer  from  anaemia,  lose  flesh  and 
strength,  have  headaches,  neuralgic  pains,  bodily  and  mental  lan- 
guor, hysteria,  and  disturbances  of  the  functions  of  the  stomach, 
liver,  and  intestines.  But  there  is  a  great  difference  in  the  patients 
as  to  how  far  these  additional  symptoms  are  developed.  In  some 
they  are  but  trifling,  in  others  they  are  well  marked. 

To  distinguish  these  patients  from  those  who  have  a  true  nephritis 
is  by  no  means  easy ;  the  diagnosis  may  remain  doubtful  for  months, 
and  even  then  it  is  difficult  not  to  make  mistakes. 

The  treatment  of  these  patients  consists  in  the  regulation  of  the 
diet  and  mode  of  life  and  the  management  of  the  disturbances  of  di- 
gestion and  of  the  condition  of  the  blood.  The  diet  should  be  liberal 
and  varied,  but  all  indigestible  articles  of  food  must  be  excluded. 
Massage,  hot  and  cold  baths,  and  regulated  exercise  are  to  be  syste- 
matically carried  out.  A  climate  which  admits  of  many  hours'  daily 
exposure  to  the  open  air  and  sunlight  is  to  be  preferred. 

All  disorders  of  digestion  are  to  be  remedied  as  far  as  possible. 

The  change  in  the  composition  of  the  blood  is  not  marked ;  neither 
the  quantity  of  haemoglobin  nor  the  number  of  blood-cells  is  much 
diminished ;  iron  is  of  service  in  the  treatment  of  the  affection,  but 
does  not  act  as  a  specific. 

The  prognosis  as  regards  the  life  and  health  of  these  patients  is 
good,  but  it  may  be  very  hard  to  get  rid  of  the  albumin  altogether. 

2.  Dietetic  Albuminuria. — This  occurs  both  in  children  and  in 
adults.  It  may  follow  the  ingestion  of  only  certain  kinds  of  food — 
cheese,  j)astry,  and  eggs ;  or  of  any  kind  of  food ;  or  of  any  food  which 
is  not  properly  digested ;  or  it  may  occur  when  exercise  follows  im- 
mediately upon  the  ingestion  of  food.  The  quantity  of  albumin  is 
small  and  there  are  few  or  no  casts. 

If  this  form  of  albuminuria  is  temporary,  it  is  not  a  serious  con- 
dition, but  if  the  disposition  to  it  persists,  the  patients  are  to  be  re- 
garded with  suspicion.  They  are  also  liable  to  temporary  glycosuria ; 
they  may  have  well-marked  functional  disturbance  of  the  liver ;  they 
may  have  the  gouty  disposition ;  or  they  may  have  cirrhosis  of  the 
liver,  or  chronic  endarteritis. 

The  treatment  consists  in  regulating  the  diet  and  exercise  in  the 
same  way  as  in  persons  with  the  gouty  disposition ;  in  relieving  con- 


UEiEMIA.  29 

stipation ;  and  in  the  use  of  the  drugs  which  are  likely  to  increase  the 
production  of  bile. 

3.  Albuminuria  after' Exertion. — The  exertion  must  be  severe  and 
prolonged,  in  long  and  fatiguing  marches  by  soldiers ;  prolonged  con- 
tests in  walking  or  running ;  violent  exercises  such  as  boxing  or  wres- 
tling. The  quantity  of  albumin  may  be  considerable  and  numerous 
casts  may  also  be  present.  It  seems  probable  that  this  form  of  albu- 
minuria is  due  to  a  congestion  of  the  kidneys  caused  by  the  exertion. 
After  the  cessation  of  the  exertion  the  albumin  regularly  disappears 
within  a  few  hours  or  days.  But  a  repetition  of  such  temporary  con- 
gestions of  the  kidney  might  lead  to  the  development  of  a  true  ne- 
phritis. 

4.  Simple  Persistent  Albuminuria. — These  patients  may  for  years 
have  small  quantities  of  albumin  nearly  every  day,  but  not  at  all 
hours  in  the  day.  The  albumin  is  not  abundant,  it  often  disappears 
after  rest;  there  may  also  be  a  few  hyaline  casts.  The  patients  have 
no  other  symptoms  of  kidney  disease,  even  when  they  are  under  ob- 
servation for  years.  But  one  always  feels  anxious  concerning  such 
persons.  Sooner  or  later  they  are  apt  to  develop  chronic  nephritis, 
or  endocarditis,  or  endarteritis. 

Ureemia. 

It  is  well  established  that  the  principal  function  of  the  kidneys 
is  to  remove  from  the  body  a  quantity  of  excrementitious  substances. 
It  is  equally  well  established  that  a  number  of  the  diseases  of  the 
kidney  interfere  with  this  function  and  allow  the  excrementitious  sub- 
stances to  accumulate  in  the  blood  and  tissues.  It  is  a  matter  of  daily 
observation  that  persons  who  suffer  from  kidney  disease  exhibit 
symxjtoms  of  such  a  character  as  to  give  the  idea  that  these  persons  are 
in  some  way  poisoned.  The  sequence  seems  to  be  logical :  disease 
of  the  kidneys,  failure  to  eliminate  excrementitious  substances,  ac- 
cumulation of  such  substances  in  the  blood  and  tissues,  poisoning  of 
the  body  by  these  substances,  the  development  of  symptoms  due  to 
the  poisoning.  To  such  a  morbid  process  the  name  of  "uraemia" 
can  properly  be  given.  So  in  the  year  1894  we  find  the  following 
definition  of  urse^nia  in  Dunglison's  Medical  Dictionary:  "Certain 
morbid  phenomena,  implicating  the  nervous  centres  more  especially, 
due  to  retention  of  excrementitious  substances  in  the  blood  which  are 
normally  excreted  by  the  kidneys,  as  in  Bright's  disease."  And  this 
definition  fairly  represents  the  poi)ular  belief  concerning  urasmia. 

Unfortunately  it  is  not  possible  to  dismiss  the  subject  in  this  easy 
way.     We  are  confronted  with  many  contradictions  difficult  of  ex- 


30  DELAFIELD — DISEASES  OF  THE  KIDNEYS. 

planation,  and  a  review  of  tlie  liistory  of  tlie  subject  shows  tliat  these 
difficulties  liave  always  been  felt. 

The  simplest  explanation  of  the  phenomena  of  uraemia — that  they 
are  due  to  the  presence  of  urea  in  the  blood — has  been  contended  for 
by  many  observers  from  the  time  of  Christison  down  to  the  present 
moment.  The  proof  has  been  derived  from  the  examination  of  the 
blood  in  human  beings,  and  from  experiments  on  animals. 

It  has  been  demonstrated  over  and  over  again  that  the  blood  of 
persons  suffering  from  ursemic  attacks  may  contain  a  large  excess  of 
urea,  that  their  serous  effusions  may  contain  large  quantities  of  urea, 
and  even  that  the  urea  may  appear  as  a  dry  powder  on  the  surface  of 
the  skin.  It  has  also  been  shown  that  in  a  number  of  cases  the  out- 
break of  ursemic  convulsions  is  preceded  by  a  diminution  in  the  ex- 
cretion of  urine  and  of  urea. 

The  experiments  on  animals  have  consisted  in  injections  of  urea 
into  the  veins,  in  the  introduction  of  urea  into  the  stomach,  and  in 
abolishing  the  function  of  the  kidneys  by  ligating  the  blood-vessels 
or  the  ureters. 

The  introduction  of  urea  in  considerable  quantities  into  the  veins 
or  into  the  stomach  is  well  borne  by  animals  provided  that  the  kid- 
neys perform  their  functions.  The  urea  is  eliminated  with  the  urine. 
If,  on  the  other  hand,  after  the  injection  of  urea  into  the  blood  the 
animal  is  entirely  deprived  of  fluids,  or  the  functions  of  the  kidney 
are  arrested  by  operation,  then  vomiting,  diarrhoea,  muscular  contrac- 
tions, and  death  regularlj^  follow. 

Ligature  of  the  blood-vessels  of  the  kidneys,  or  of  their  ureters,  or 
extirpation  of  the  kidneys  is  followed  by  an  accumulation  of  urea  in 
the  blood  and  tissues.  The  animals  have  vomiting  and  diarrhoea, 
become  stupid,  and  die. 

The  contradictions  to  this  theory  of  uraemia  were  soon  noted. 
Owen  Eees  was  one  of  the  first  to  call  attention  to  the  fact  that  pro- 
longed anuria  is  not  necessarily  accompanied  with  renal  symptoms. 
His  illustrative  case  was  a  patient  in  whom  one  kidney  was  absent ; 
the  ureter  of  the  other  kidney  became  blocked  by  a  calculus,  and 
there  was  complete  suppression  of  urine.  The  quantity  of  urea  in 
the  blood  was  much  increased.  The  patient  died,  but  there  were 
no  ursemic  symptoms.  Cases  of  suppression  of  urine  lasting  for  a 
number  of  days  are  not  infrequent,  and  the  ordinary  experience  has 
been  that  it  is  precisely  in  these  cases  that  ursemic  symptoms  are 
absent,  although  death  regularly  follows. 

More  than  this,  Bartels  and  others  have  found  that  the  blood  drawn 
immediately  after  a  ursemic  attack  may  contain  no  excess  of  urea.  It 
is  a  matter  of  ordinary  experience  that  ursemic  symptoms  may  come 


UREMIA.  31 

on  in  persons  wlio  are  passing  a  normal  quantity  of  urine  of  good 
specific  gravity.  So  there  seems  to  be  no  escape  from  the  facts  that 
complete  suppression  of  urine  is  not  regularly  followed  by  urgemic 
symptoms,  and  that  urssmic  symptoms  may  occur  without  an  excess 
of  urea  in  the  blood,  or  a  diminution  in  the  excretion  of  normal  urine. 

So  far  as  the  experiments  on  animals  are  concerned  they  seem 
merely  to  show  that  urea  in  the  blood  does  but  little  harm,  and  that 
abolition  of  the  functions  of  the  kidneys  causes  death. 

It  was  to  escape  from  some  of  these  difficulties  that  Frerichs  pro- 
posed the  explanation  that  the  cause  of  ursemic  symptoms  was  poi- 
soning by  carbonate  of  ammonia.  He  taught  that  urea  in  excess  in 
the  blood  did  no  special  harm,  but  that  if  by  the  action  of  some  fer- 
ment the  urea  was  changed  into  carbonate  of  ammonia,  then  symp- 
toms of  intoxication  would  regularly  follow.  This  theory,  at  one 
time  popular,  is  now  so  entirely  abandoned  that  it  is  not  necessary 
to  state  the  objections  to  it. 

A  modification  of  the  theory  of  intoxication  by  urea  is  that  of  in- 
toxication by  urea  and  the  other  excrementitious  substances  of  the 
urine  together.  The  same  affirmative  and  negative  facts  are  to  be 
found  for  this  theory  as  for  that  of  poisoning  by  urea  alone.  Normal 
uncontaminated  urine  injected  into  the  veins  of  animals  seems  to  do 
little  harm  unless  the  kidneys  of  these  animals  are  injured  by  opera- 
tion.    If  the  kidneys  are  operated  on,  the  animals  die. 

In  human  beings  there  are  the  patients  with  ursemic  symptoms  and 
an  excess  of  excrementitious  substances  in  their  blood  and  tissues ; 
the  patients  with  urgemic  symptoms,  but  without  any  excess  of  excre- 
mentitious substances ;  and  the  patients  with  anuria,  an  excess  of 
excrementitious  substances,  and  no  ursemic  symptoms. 

A  very  important  modification  of  the  chemical  aspect  of  the  ques- 
tion is  that  made  by  Oppler  and  others.  They  hold  that  it  is  an 
error  to  think  that  urea  or  any  other  constituent  of  the  urine  acts  as  a 
blood  poison.  Bather  an  interference  with  the  functions  of  the  kid- 
neys must  lead  to  a  disturbance  of  the  regular  chemical  changes  in 
all  parts  of  the  body.  Such  an  interference  is  followed  by  a  change 
in  the  nutrition  of  the  tissues  which  shows  itself  in  loss  of  weight,  in 
angemia,  and  in  disturbances  of  the  functions  of  the  brain.  This  way 
of  looking  at  the  subject  is  certainly  a  very  rational  one. 

The  opposition  to  all  the  chemical  explanations  of  uraemia  looks 
to  changes  in  the  blood  pressure  as  the  exciting  cause  of  ursemic  at- 
tacks.    The  most  complete  theory  of  this  kind  is  that  of  Traube. 

This  theory  explains  the  occurrence  of  ursemic  attacks  as  follows : 
The  disease  of  the  kidneys  causes  thinning  of  the  blood  serum,  hyper- 
trophy of  the  left  ventricle  of  the  heart,  and  an  excess  of  blood  pres- 


6Z  DELAPIELD — DISEASES   OP  THE   KIDNEYS. 

sure  in  the  arteries.  If  by  any  accidental  circumstance  tlie  blood 
tension  is  suddenly  increased,  or  tlie  blood  serum  still  further  thinned, 
oedema  and  anaemia  of  the  brain  are  produced.  The  form  of  the  urse- 
mic  attack  will  vary  with  the  portion  of  the  brain  which  is  rendered 
ansemic  or  oedematous.  If  the  cerebral  hemispheres  alone  are  in- 
volved the  patient  simply  becomes  comatose ;  if  the  central  portions  of 
the  brain  alone  are  affected  there  will  be  convulsions  without  coma ; 
if  both  the  hemispheres  and  the  central  portions  of  the  brain  are 
ansemic  and  oedematous,  both  convulsions  and  coma  are  developed. 

Traube  also  states : 

That  he  never  saw  an  attack  of  ursemia  in  renal  disease  where  the 
left  ventricle  of  the  heart  was  not  hypertrophied,  and  where  an  in- 
crease of  tension  in  the  aortic  system  could  not  be  demonstrated ; 

That  the  diluted  state  of  the  blood  serum  can  be  recognized  by 
the  pallor  of  the  skin  and  mucous  membranes,  and  the  presence  of 
dropsical  effusions ; 

That  in  every  instance  in  which  he  examined  the  brain  after 
death  he  could  confirm  the  existence  of  anaemia  and  oedema ; 

That  the  presence  of  blood  effusion  within  the  cranial  cavity  in 
vaanj  of  these  cases  confirms  the  suspicion  that  the  abnormally  high 
arterial  blood  pressure  to  which  these  effusions  owe  their  origin  has 
also  something  to  do  with  the  production  of  the  cedema  which  is  pres- 
ent at  the  same  time. 

Experiments  on  animals  have  also  shown  that  by  ligating  the 
ureters,  then  the  jugular  vein  on  one  side,  and  then  injecting  water 
into  the  carotid  on  the  same  side,  general  convulsions  and  coma  can  be 
produced.  After  death  oedema  of  the  brain  without  extravasation  of 
blood  is  found. 

The  objections  to  Traube 's  theory  are  obvious :  In  patients 
who  exhibit  well-marked  cerebral  symptoms  the  specific  gravity  of 
the  blood  serum  is  not  always  lowered ;  the  arterial  tension  is  not 
always  increased;  neither  ansemia  nor  oedema  of  the  brain  can 
always  be  demonstrated  after  death.  These  are  facts  which  are  soon 
ascertained  by  any  one  who  sees  much  of  kidney  disease. 

The  marked  ursemic  symptoms  which  occur  at  the  close  of  preg- 
nancy, and  are  known  under  the  name  of  puerperal  eclampsia,  differ 
from  ordinary  ursemic  attacks  in  that  they  may  occur  without  marked 
structural  changes  in  the  kidneys.  A  variety  of  explanations  have 
been  offered  as  to  their  causation. 

The  older  British  and  American  obstetricians  taught  that  puer- 
peral convulsions  were  caused  by  determination  of  blood  to  the  head- 
cerebral  congestion.  Traube's  theory  of  altered  blood,  increased 
arterial  tension,  with  anaemia  and  oedema  of  the  brain  can  be  applied 


*     UREMIA.  33 

to  the  puerperal  cases  of  uraemia  as  well  as  to  those  associated  with 
kidney  disease. 

A  retention  in  the  blood  of  some  toxic  agent,  with  consequent 
poisoning  of  the  blood  centres,  has  been  a  favorite  theory  with  many. 
The  toxic  material  has  been  thought  to  be :  urea,  carbonate  of  am- 
monia, urea  with  kreatin  and  other  excrementitious  substances,  or 
ptomaines  produced  by  the  growth  of  bacteria. 

The  convulsions  are  attributed  by  some  to  cerebro-spinal  disturb- 
ance from  peripheral  stimulation  quite  independently  of  the  kid- 
neys. Others  believe  that  the  convulsions  are  due  to  blood  poison- 
ing, but  that  the  renal  disturbance  which  causes  the  blood  poisoning 
is  due  to  vasomotor  spasm  of  the  small  renal  vessels  with  conse- 
quent degenerative  changes  in  the  kidneys,  the  vasomotor  spasm  re- 
sulting from  some  reflex  irritation. 

It  is  also  believed  that  some  i^uerperal  convulsions  are  simply 
acute  epileptic  attacks,  the  area  of  distribution  of  the  sciatic  nerve 
being  the  epileptogenic  zone. 

More  recently  attention  has  been  called  to  the  probability  that  the 
so-called  ursemic  symptoms  are  due  to  a  poison  in  the  blood,  but 
that  this  poison  is  not  due  to  any  disturbance  of  the  function  of  the 
kidneys.  This  idea  is  only  a  theory,  but  it  offers  a  promising  field 
for  study.  It  may  very  well  be  that  we  must  look  for  the  cause  of 
these  symptoms  altogether  outside  of  the  kidneys.  ' 

It  is  evident  from  what  has  been  said  that  there  is  no  entirely  sat- 
isfactory way  of  accounting  for  the  so-called  ursemic  symptoms.  At 
the  present  time  the  only  very  useful  thing  to  do  is  to  try  and  state 
as  clearly  as  possible  the  conditions  of  the  problem  which  we  wish 
to  solve. 

The  symptoms  which  it  is  customary  to  call  ursemic  are : 

1.  Heado^che  and  sleeplessness,  which  come  on  in  attacks  of  short 
duration,  or  may  be  continued  for  many  weeks.  The  headache  may 
be  of  mild  type,  or  very  severe.  In  extreme  cases  the  pain  is  so  se- 
vere and  the  sleeplessness  so  distressing  that  the  patients  are  almost 
maniacal.     These  symptoms  may  accompany : 

(a)  Puerperal  Eclampsia  either  with  or  without  Nephritis.  At 
the  time  of  the  attack  the  urine  is  diminished  in  quantity  but  of  good 
specific  gravity.  The  arteries  are  full  and  tense,  the  heart's  action 
is  exaggerated,  the  veins  are  congested.  The  headache  can  be  relieved 
[by  the  birth  of  the  child,  by  general  blood-letting,  by  morphine,  and 
by  the  drugs  which  dilate  the  arteries. 

Q})  Acute  Exudative  and  Acute  Productive  Nephritis.  At  the 
time  of  the  attack  the  urine  is  often,  but  not  always,  diminished ;  its 
specific  gravity  is  good.  The  arteries  are  full  and  tense,  the  heart's 
Vol.  I.— 3 


34  DELAPEELD — DISEASES   OF  THE   KIDNEYS. 

action  is  exaggerated.  The  lieadaclie  can  be  relieved  by  the  arterial 
dilators,  by  morphine,  by  purging,  by  sweating.  General  blood-let- 
ting can  but  seldom  be  used. 

(c)  Chronic  Nephritis  with  Exudation.  The  urine  is  often  dimin- 
ished but  may  be  increased  in  quantity ;  its  specific  gravity  is  low. 
The  condition  of  the  arteries  and  heart  is  not  constant.  The  arteries 
may  be  full  and  tense,  or  small  and  tense,  or  full  and  soft,  or  small 
and  feeble.  The  heart's  action  may  be  exaggerated,  or  feeble;  the 
valves  may  be  diseased,  or  the  left  ventricle  hypertrophied.  The 
headache  can  sometimes  be  relieved,  but  late  in  the  disease  nothing 
will  control  it.  The  arterial  dilators  are  of  use  only  when  the  pulse 
is  tense.  The  cardiac  stimulants  may  do  good  when  the  heart's 
action  is  feeble.  Thorough  daily  sweating  is  sometimes  efiicient. 
Purging  can  give  temporary  relief.  Opium  may  be  the  only  drug 
that  is  of  any  use.  Mild  cases  can  be  relieved  by  improving  the 
action  of  the  digestive  tract. 

{d)  Chronic  Nephritis  without  Exudation.  The  headache  and 
sleeplessness  are  especially  frequent  and  severe  with  this  form  of 
nephritis.  The  urine  is  often  diminished,  but  may  be  increased  or 
normal  in  quantity ;  its  specific  gravity  is  low.  The  condition  of  the 
heart  and  arteries  is  liable  to  the  same  variations  as  in  chronic  ne- 
phritis with  exudation,  but  a  full,  tense  pulse  and  an  hypertrophied  left 
ventricle  are  more  regularly  present.  The  first  attack  of  headache 
can  usually  be  relieved,  but  each  successive  attack  is  more  difficult  to 
manage. 

2.  Hemiplegia  and  Ajjhasia. — These  two  symptoms,  which  may 
occur  separately  or  together,  are  seen  in  patients  who  have  chronic 
nephritis  without  exudation,  and  in  women  with  puerperal  eclampsia. 
The  invasion  of  the  hemiplegia  is  sudden  and  it  is  usually  accom- 
panied by  coma.  There  is  loss  of  motion  alone  or  of  both  motion 
and  sensation.  The  hemiplegia,  coma,  and  aphasia  may  continue  up 
to  the  time  of  the  patient's  death,  or  disappear  after  a  few  days.  In 
the  latter  case  the  patient  may  have  several  such  attacks.  In  chronic 
nephritis  the  hemiplegia  may  occur  either  early  or  late  in  the  course 
of  the  disease.  In  these  patients  chronic  endarteritis,  especially  of 
the  cerebral  arteries,  is  very  regularly  present.  I  think  that  it  is 
probable  that  the  hemiplegia  is  due  to  the  endarteritis,  rather  than  to 
the  kidney  disease. 

The  treatment  of  this  condition  is  not  satisfactory.  If  there  is 
well-marked  arterial  tension  it  may  be  proper  to  try  and  reduce  it, 
otherwise  it  is  better  not  to  interfere. 

3.  Sudden  Blindness. — Besides  the  loss  of  vision  due  to  nephritic 
retinitis,  tnere  may  be  a  sudden  blindness  which  lasts  for  hours  or 


URiEMIA.  35 

days.  In  these  patients  no  anatomical  changes  in  the  eyes  have  been 
discovered.  This  form  of  blindness  is  not  uncommon  in  puerperal 
eclampsia ;  it  occurs  in  a  moderate  number  of  the  cases  of  chronic  ne- 
phritis. We  do  not  understand  the  nature  or  treatment  of  this  blind- 
ness ;  fortunately  it  only  lasts  for  a  short  time. 

4.  General  Epileptiform  Convulsions. — These  have  always  attracted 
much  attention  as  one  of  the  most  terrible  and  dangerous  of  the  re- 
sults of  kidney  disease.     They  may  accompany : 

(a)  Puerperal  Eclampsia,  either  with  or  without  nephritis,  com- 
ing on  either  before,  during,  or  after  labor.  At  the  time  of  the  at- 
tack the  urine  is  sometimes  diminished  or  suppressed,  sometimes  of 
normal  quantity.  The  arteries  are  regularly  full  and  tense,  the 
heart's  action  is  exaggerated,  the  skin  is  congested.  It  seems  to  be 
generally  conceded  that  in  these  patients  the  convulsions  are  not  all 
due  to  the  same  cause.  There  is  also  a  substantial  agreement  as  to 
the  best  methods  of  treatment.  General  blood-letting  for  the  pa- 
tients with  excessive  venous  congestion,  chloroform  inhalations  for 
the  irritable  jjatients,  and  the  drugs  which  dilate  the  arteries  are 
the  routine  treatment. 

(b)  Both  Forms  of  Acute  Nephritis.  In  children  suffering  from 
acute  nephritis  convulsions  are  of  quite  frequent  occurrence,  even 
when  the  disease  is  not  of  severe  type.  So  many  children  recover 
after  one  or  more  convulsions  that  they  are  not  grave  symptoms.  In 
adults  convulsions  do  not  occur  nearly  as  often  as  in  children,  but 
the  patients  are  much  more  likely  to  die.  In  children  general  blood- 
letting can  very  seldom  be  practised ;  in  adults  there  are  a  few  cases 
in  which  it  is  appropriate.  In  most  of  the  patients  the  drugs  which 
dilate  the  arteries  give  altogether  the  best  results. 

(c)  Chronic  Nephritis  with  Exudation.  The  convulsions  belong  to 
the  advanced  cases  of  the  disease,  to  the  patients  who  are  dropsical, 
anaemic,  and  apparently  thoroughly  poisoned  with  excrementitious 
substances.  The  heart's  action  and  the  pulse  are  feeble.  In  these 
patients  it  is  difficult,  or  impossible,  to  control  the  convulsions.  The 
most  efficient  jjlan  seems  to  be  the  daily  sweating  with  the  hot  pack. 

There  are  cases  of  chronic  nephritis  with  exudation  in  which  an 
exacerbation  of  the  inflammation  takes  place,  and  the  patients  then 
l^ehave  much  as  if  they  had  an  acute  nephritis. 

id)  Chronic  Nephritis  without  Exudation.  Convulsions  are  of 
frequent  occurrence  early  in  the  disease  as  well  as  late ;  indeed,  in 
many  j^ersons  the  attack  of  convulsions  is  the  first  symijtom  of  the 
nephritis.  Many  of  the  patients  have  hypertrophy  of  the  left  ven- 
tricle of  the  heart  and  chronic  endarteritis  in  addition  to  the  ne- 
jjhritis.     Common  as  these  attacks  are,  their  causation  is  most  ob- 


36  DELAFIELD— DISEASES   OF   THE   KIDNEYS. 

scure,  for  tliere  can  be  no  question  tliat  the  liability  to  the  convul- 
sions is  not  at  all  in  proportion  to  the  failure  of  the  functions  of  the 
kidneys.  Certainly  a  marked  increase  in  arterial  tension  is  the  rule 
with  these  attacks,  and  the  control  of  the  convulsions  is  in  propor- 
tion to  the  success  in  dilating  the  arteries.  But  there  are  cases  in 
which  we  are  not  able  either  to  dilate  the  arteries  or  to  control  the  con- 
vulsions ;  and  there  are  cases  in  which  the  convulsions  continue  al- 
though the  pulse  becomes  rapid  and  feeble.  It  is  for  the  convulsions 
vnth.  this  form  of  nephritis  that  hj^podermics  of  morphine  are  of  so 
much  efficacy  for  a  time.  It  must  be  admitted  that  when  a  patient 
with  chronic  nephritis  begins  to  have  convulsions  death  is  not  far  off. 

5.  Contractions  of  Groups  of  3Iuscles. — These  are  of  common  occur- 
rence in  the  severe  forms  of  acute  and  chronic  nephritis  and  in  puer- 
peral eclampsia.  Very  often  they  merely  j^recede  an  attack  of  general 
convulsions.  They  are  best  marked  and  of  longest  continuance  in 
the  advanced  cases  of  chronic  nej)hritis  with  exudation. 

6.  Delirium  and  Coma. — They  come  on  suddenly  in  attacks,  either 
associated  with  con^-ulsions  or  by  themselves ;  or  they  are  developed 
slowly  and  graduall}'  and  continue  for  a  considerable  length  of  time. 
The  attacks  belong  to  the  severe  cases  of  acute  nephritis,  to  the  ex- 
acerbations of  chronic  nephritis  with  exudation,  and  to  the  ordinary 
cases  of  chronic  nephritis  without  exudation.  The  gradual  develop- 
ment of  delirium  and  coma  is  apt  to  continue,  although  sometimes 
with  intervals  of  improvement,  up  to  the  time  of  the  patient's  death. 
They  are  very  often  seen  in  the  advanced  stages  of  both  forms  of 
chronic  nephritis. 

7.  Vomiting  is  seen  in  many  cases  of  nephritis.  It  is  evidently 
due  to  a  number  of  different  causes.  In  acute  nephritis  the  vomiting 
seems  to  be  of  the  same  character  as  that  which  may  occur  with  an 
acute  inflammation  of  any  part  of  the  body.  In  chronic  nephritis  the 
vomiting  may  be  due  to  chronic  gastritis ;  or  the  stomach,  like  the 
intestine,  gets  rid  of  some  of  the  accumulated  urea  and  serum. 

Besides  these  forms  of  vomiting  there  is  a  special  and  aggravated 
form  which  belongs  regularly  to  the  cases  of  chronic  nephritis  with- 
out exudation.  It  is  usually  accompanied  by  a  marked  increase  of 
arterial  tension.  The  vomiting  is  frequent,  distressing,  and  may  con- 
tinue for  days.  The  most  efficient  means  of  controlling  it  are  chloral 
hydrate  by  the  rectum  in  twenty-grain  doses,  or  hypodermic  injections 
of  morphine. 

8.  A  Rise  of  Temperature. — In  acute  nephritis,  as  in  any  other 
acute  inflammation,  there  may  be  a  febrile  movement.  As  a  rule  the 
temperature  is  not  high  and  falls  to  the  normal  within  a  week.  But 
in  children  temperatures  of  104°  or  105°  F.  may  be  reached. 


URiEMIA.  37 

In  chronic  nephritis  the  severe  attacks  of  cerebral  symjjtoms — 
headache,  convulsions,  delirium,  coma,  hemiplegia — are  not  infre- 
quently accompanied  with  a  considerable  rise  of  temperature.  I  have 
seen  it  as  high  as  109°  F.,  and  yet  the  autopsies  show  no  reason  for 
the  febrile  movement. 

9.  Dyspnoea  is  one  of  the  most  frequent  and  interesting  of  the 
symptoms  of  nephritis.  There  is  a  dyspnoea  due  to  fluid  in  the  pleural 
cavities,  or  to  cedema  of  the  lungs ;  a  dyspnoea  due  to  pressure  on  the 
diaphragm  by  fluid  in  the  abdomen;  and  a  dyspnoea  due  to  bronchitis 
or  to  contraction  of  the  bronchi ;  but  the  most  important  form  of 
dyspnoea  is  one  which  is  independent  of  all  these  causes  and  is  di- 
rectly caused  by  disturbances  of  the  circulation.  It  belongs  to  both 
forms  of  chronic  nephritis,  but  is  more  common  with  nephritis  with- 
out exudation.  The  i)atients,  as  a  rule,  in  addition  to  the  nephritis 
have  pulmonary  emphysema,  chronic  endarteritis,  hypertrophy  of 
the  left  ventricle,  or  chronic  endocarditis.  Not  infrequently  one  or 
more  of  these  lesions  are  much  more  advanced  and  apparently  more 
important  than  the  kidney  disease.  Especially  is  this  the  case  with 
chronic  endarteritis,  which  gives  many  of  the  most  marked  examples 
of  this  form  of  dyspnoea  with  but  very  little  nephritis. 

The  dyspnoea  may  come  on  at  any  time  in  the  course  of  a  ne- 
phritis ;  very  often  it  is  the  flrst  symptom  which  causes  the  patient 
to  seek  medical  advice.  It  begins  with  attacks,  which  at  first  are 
brought  on  by  bodily  and  mental  exertion,  or  come  on  of  themselves 
at  an  early  hour  in  the  morning.  In  none  of  the  attacks  do  we  hear 
the  characteristic  breathing  of  bronchial  asthma.  The  attacks  at 
first  only  last  for  an  hour  or  so,  and  during  the  rest  of  the  day  the 
breathing  is  comfortable.  But  even  in  these  mild  attacks  the  patients 
cannot  lie  down.  As  time  goes  on  the  attacks  become  more  frequent 
and  of  longer  duration.  Finally  comes  the  terrible  period  when  the 
breathing  is  always  bad,  the  patients  cannot  lie  down  at  all,  and  yet 
go  on  living  for  weeks  and  months. 

The  treatment  of  this  dysfmoea  is  often  for  a  time  extremely 
satisfactory.  The  patients  are  enabled  to  live  and  work  in  comfort  for 
many  years.  But  each  succeeding  attack  is  harder  to  control  than 
the  first,  and  finally  there  comes  a  time  when  everything  fails  and 
the  dyspnoea  continues  although  the  patient  is  stupefied  with  drugs. 

The  object  of  treatment  is  to  relieve  the  disturbances  of  the  cir- 
culation; if  this  can  be  done  the  dyspnoea  is  also  relieved.  To  effect 
this  the  most  exact  study  of  the  circulation  is  required.  For  each 
patient  the  character  of  the  heart's  action  and  of  the  pulse,  both 
relatively  and  separately,  must  be  determined.  Based  on  this  knowl- 
edge is  the  intelligent  use  of  cardiac   stimulants  and  sedatives,  of 


38  DELAPIELD — DISEASES  OF  THE  KIDNEYS. 

arterial  dilators,  of  regulation  of  tlie  functions  of  the  stomacli,  liver, 
and  intestines,  of  rest  or  exercise.  There  is  no  one  plan  of  treatment 
for  all,  nor  even  one  plan  for  the  same  patient  in  all  attacks. 

Increased  Arterial  Tension. — This  is  not  always  classed  with  the 
ursemic  symptoms.  It  is,  however,  one  of  the  most  frequent  and 
important  of  the  symptoms  of  chronic  nephritis,  and  it  is  by  it  that 
many  of  the  so-called  ureemic  symptoms  are  produced. 

It  has  been  believed  that  this  increased  tension  of  the  blood  in  the 
arteries  is  due  to  chronic  changes  in  the  walls  of  the  arteries  and 
capillaries  which  interfere  with  the  passage  of  the  blood  through 
them.  The  explanation  is  very  probably  tine  up  to  a  certain  point, 
but  it  does  not  account  for  the  attacks  of  increased  arterial  tension 
which  come  and  go  within  a  few  hours.  I  do  not  see  how  these 
can  be  produced  except  by  the  temporary  contraction  of  arteries  which 
have  a  well-developed  muscular  coat,  such  as  the  radial  artery.  I 
think  that  it  is  possible  to  demonstrate  after  death  in  such  arteries 
an  hj^pertrophy  of  the  muscular  coat,  in  patients  who  have  had  many 
attacks  of  increased  arterial  tension. 

If  this  is  admitted,  then  we  have  to  find  a  reason  for  the  attacks 
of  contraction  of  the  arteries  which  last  for  hours  or  for  weeks,  and 
which  can  often  be  controlled  by  the  drugs  which  dilate  the  arteries. 

Such  attacks  of  contraction  of  the  arteries  occur  with : 

Angina  pectoris ; 

Chronic  endocarditis ; 

Chronic  arteritis ; 

Pulmonary  emphysema ; 

Chronic  nephritis. 

It  seems  as  if  such  a  contraction  of  the  arteries  must  be  due  to 
some  irritating  substance  in  the  blood.  But  whether  there  is  only 
one  poison  which  acts  in  this  way  or  several  poisons,  and  how  such 
poison  or  poisons  are  produced,  we  do  not  know. 


Acute  Congestion  of  the  Kidneys. 

Definition. 

A  temporary  congestion  of  the  blood-vessels  of  the  kidney,  which 
may  be  accompanied  with  exudation  of  serum  and  escape  of  red  blood- 
cells. 

Etiology. 

Acute  congestion  is  caused  by  the  ingestion  of  certain  poisons,  by 
extirpation  of  one  of  the  kidneys,  by  severe  injuries  inflicted  on  any 


ACUTE   CONGESTION  OF  THE  KIDNEYS.  39 

part  of  tlie  body,  by  surgical  operations,  especially  those  on  the  blad- 
der and  urethra,  and  by  over-exei'tion. 


MoEBiD  Anatomy. 

It  is  but  seldom  that  we  are  able  to  obtain  human  kidneys  in  the 
state  of  acute  congestion,  for  the  condition  is  not  usually  a  fatal  one. 
In  animals,  however,  the  condition  can  be  produced  experimentally 
by  cantharidin.  It  is  found  that  the  kidneys  are  enlarged,  that  the 
veins,  capillaries,  and  Malpighian  tufts  contain  an  increased  quantity 
of  blood,  and  that  the  epithelial  cells  of  the  cortex  tubes  are  flattened. 

Symptoms. 

Acute  congestion  may  occur  in  kidneys  previously  normal,  or  in 
those  already  diseased. 

The  urine  is  diminished  in  quantity  or  suppressed;  its  sijecific 
gravity  is  unchanged ;  it  contains  blood,  albumin,  and  casts. 

(1)  Congestion  Caused  by  the  Ingestion  of  Poisons. 

Cantharides  given  internally,  or  used  in  blisters  or  ointment,  is 
rather  a  frequent  cause  of  acute  congestion  of  both  the  kidneys  and 
the  bladder. 

The  urine  is  diminished  in  quantity ;  it  is  passed  frequently,  in 
small  quantities,  with  much  pain ;  or  it  is  retained.  It  contains  albu- 
min, a  few  casts,  and  blood.  Sometimes  large,  jelly-like  coagula  are 
formed  in  the  bladder. 

The  patients  may  have  a  moderate  rise  of  temperature,  pain  in 
the  back,  abdominal  pain,  nausea  and  vomiting,  diarrhoea,  more  or 
less  prostration,  delirium,  and  stupor.  The  severity  of  the  symptoms 
depends  on  the  quantity  of  the  drug  absorbed.  In  the  bad  cases  of 
poisoning  the  condition  of  the  kidneys  is  not  that  of  hypersemia,  but 
of  actual  inflammation. 

When  there  is  only  hypersemia  the  patients  are  sick  for  a  few  days, 
and  the  urine  soon  returns  to  its  natural  condition.  Turpentine  pro- 
duces symptoms  like  those  of  cantharides. 

Treatment. — If  the  poison  has  been  taken  into  the  stomach,  that 
organ  is  to  be  emptied  and  washed  out.  Warm  baths,  or  a  hot  pack, 
and  the  use  of  small  doses  of  opium  are  of  service.  Camphor  in  doses 
of  from  2  to  5  grains  every  three  hours  has  been  recommended  in 
cantharides  poisoning. 


40  DELAPIELD — DISEASES   OF  THE   KIDNEYS. 

(2)  Congestion  Following  the  Removal  of  One  Kidney. 

The  uriue  is  scanty  or  suppressed,  and  contains  albumin  and 
casts.  Tlie  patients  are  in  a  condition  of  prostration  which  is  very 
alarming.  Thej^  may  remain  in  this  condition  for  a  few  days  and 
then  recover,  the  urine  returning  after  a  time  to  its  natural  condition ; 
or  they  become  more  and  more  feeble,  pass  into  the  tj^phoid  con- 
dition with  mild  delirium,  and  die. 

Treatment. — The  patients  are  to  be  kept  perfectly  quiet  in  bed,  on 
a  fluid  diet.  They  should  have  one  or  two  long  hot  packs  every  day 
so  as  to  produce  congestion  of  the  skin  and  profuse  perspiration. 

(3)  Congestion  after  Injuries,  or  Surgical  Operations. 

It  is  well  known  that  any  operation  on  the  bladder  or  urethra, 
even  the  passage  of  a  catheter,  may  be  followed  by  suppression  of 
urine,  great  prostration,  and  death  within  forty-eight  hours,  and  that 
after  death  no  lesion  is  found  except  congestion  of  the  kidneys. 
These  cases  are  not  to  be  confounded  with  the  cases  of  septic  infec- 
tion and  fever,  which  may  also  follow  operations  on  the  urethra  and 
bladder. 

It  is  not  so  well  known  that  surgical  operations  on  any  part  of  the 
body  are  occasionally  followed  by  suppression  of  urine,  congestion 
of  the  kidneys,  and  death.  We  do  not  know  that  death  in  all  these 
cases  is  caused  by  the  congestion  of  the  kidneys,  but  there  can  be  no 
question  that  congestion  of  the  kidneys  is  produced  in  this  way. 

Treatment. — No  satisfactory  treatment  has  yet  been  found  for  these 
patients ;  in  fact,  the  very  short  time  which  intervenes  between  the 
operation  and  death  hardly  gives  time  for  treatment. 

(4)  Acute  Congestion  after  Over-Exertion. 

Prolonged  marches,  ^dolent  gymnastic  exercises,  contests  of  walk- 
ing and  running  prolonged  over  several  days  may  be  followed  by  the 
excretion  of  such  a  quantity  of  albumin  and  casts  in  the  urine  as  to 
indicate  a  temporary  congestion.  I  do  not  know  of  any  post-mortem 
observations  which  corroborate  this  belief.  There  are  no  other 
symptoms  besides  the  changes  in  the  urine,  and  these  disappear 
after  a  few  days'  rest. 

Chronic  Congestion  of  the  Kidneys. 

There  are  a  number  of  morbid  conditions  which  interfere  with  the 
circulation  of  the  blood  in  the  aortic  system  in  such  a  way  that  the 


CHRONIC   CONGESTION   OF  THE   KIDNEYS.  41 

blood  accumulates  in  tlie  veins  and  is  diminished  in  the  arteries. 
The  most  common  of  these  conditions  are :  chronic  inflammation  of 
the  aortic  and  mitral  valves,  dilatation  of  the  heart,  aneurism  of  the 
arch  of  the  aorta,  pulmonary  emphysema,  and  large  accumulations  of 
fluid  in  the  pleural  cavities. 

In  pulmonary  emphysema  the  disturbances  of  circulation  are  con- 
fined to  the  cases  in  which  there  is  obstruction  to  the  passage  of 
blood  through  the  lungs,  dilatation  and  hypertrophy  of  the  right  ven- 
tricle, and  then  venous  congestion  of  the  aortic  system.  More  or  less 
dropsy  is  regularly  developed  at  about  the  same  time  as  the  conges- 
tion of  the  kidneys. 

Large  accumulations  of  fluid  in  the  pleural  cavities,  if  they  remain 
for  any  length  of  time,  may  produce  well-marked  chronic  congestion. 
This  is  denied  by  Bartels,  who  says  that  he  has  never  known  conges- 
tion or  any  serious  disturbance  of  the  renal  functions  to  occur  as  a 
result  of  pleuritic  exudations.  I  have,  however,  seen  congestion  pro- 
duced in  this  way  a  number  of  times.  I  think  that'  it  is  a  lesion  of 
consequence  to  the  patient,  and  I  believe  that  it  furnishes  an  addi- 
tional reason  for  the  early  removal  of  fluid  from  the  pleural  cavities. 

Etiology. 

By  far  the  most  common  cause  of  chronic  congestion  of  the  kid- 
neys is  disease  of  the  heart.  So  long  as  a  heart  with  chronic  en- 
docarditis, or  myocarditis,  or  dilatation  is  able,  in  spite  of  its  dam- 
aged state,  to  carry  on  the  circulation  fairly  well,  no  secondary 
changes  in  the  kidneys  are  produced.  But  as  soon  as  the  blood 
accumulates  in  the  veins  to  any  considerable  extent  the  kidneys 
suffer.  One  of  three  things  regularly  happens  to  them:  either 
chronic  congestion,  or  chronic  degeneration,  or  chronic  nephritis  is 
developed.  It  is  also  necessary  to  remember  that  chronic  endocar- 
ditis and  chronic  nephritis  often  exist  in  the  same  person,  although 
neither  one  of  them  is  secondary  to  the  other. 

Morbid  Anatomy. 

The  kidneys  are  of  medium  size,  or  rather  large.  Their  weight  is 
increased  somewhat  out  of  proportion  to  the  increase  in  size.  The 
color  is  dark-red,  the  consistence  is  very  hard,  the  surfaces  are 
smooth,  the  cai)sules  are  not  adherent.  The  congestion  is  most 
marked  in  the  veins  of  the  x^yramids ;  they  contain  an  increased  quan- 
tity of  l)lood,  and  are  often  dilated.  The  capillaries  of  the  cortex  are 
also  congested,  but  it  is  rather  exceptional  to  find  them  dilated.     The 


42 


DELAITELD— DISEASES   OE  THE  KIDNEYS. 


epitlielium  of  the  convoluted  tubes  is  swollen,  and  tlie  separate  cells 
of  wMcli  it  is  composed  are  more  evident.  Or,  instead  of  this,  the 
epithelium  is  much  flattened  so  that  the  lumen  of  the  tube  is  larger. 
I  think  that  this  flattening  of  the  epithelium  belongs  to  the  kidneys 
which  give  urine  containing  a  good  deal  of  albumin. 

The  most  constant  and  characteristic  change  is  in  the  glomeruli. 
The  capillaries  which  make  up  the  glomerulus  are  dilated,  with  more 
or  less  thickening  of  their  walls.     So  far  as  I  know  this  change  in 


Fig.  1.— Cortex  Tubes.    Chronic  Congestion  of  the  Kidney. 

the  glomeruli  is  constant  and  persists,  even  if  the  congestion  is  suc- 
ceeded by  a  true  nephritis. 

While  the  congestion  often  persists  up  to  the  time  of  the  patient's 
death,  it  may,  instead  of  this,  be  followed  by  an  acute  or  a  chronic 
nephritis. 

If  there  is  an  acute  nephritis  albumin  is  present  in  considerable 
quantities  in  the  urine.  After  death  the  glomeruli,  in  addition  to 
the  dilatation  of  their  capillaries,  show  an  increase  in  the  size  and 
number  of  the  cells  which  cover  them.  The  epithelium  of  the  con- 
voluted tubes  is  flattened. 


CHEONIC  CONGESTION  OF  THE  KIDNEYS.  43 

If  there  is  a  clironio  nephritis  the  specific  gravity  of  the  urine  falls 
and  the  excretion  of  urea  is  diminished.  The  nephritis  follows  the 
anatomical  type  of  a  chronic  nephritis  without  exudation,  but  the 
dilatation  of  the  capillaries  of  the  glomeruli  persists. 

Symptoms. 

Of  the  persons  who  die  with  chronic  congestion  of  the  kidneys  a 
large  number  present  marked  symptoms  during  life,  but  it  is  difficult 
to  determine  how  largely  these  symptoms  are  due  to  the  congestion 
of  the  kidneys. 

A  congestion  of  a  few  weeks'  duration,  such  as  we  see  with  large 
effusions  of  fluid  in  the  pleural  cavities,  seems  to  give  no  renal  symp- 
toms and  no  changes  in  the  urine. 

The  question  is  complicated  by  the  fact  that  with  chronic  endo- 
carditis and  pulmonary  emphysema  any  one  of  the  following  kidney 
lesions  may  coexist:  1.  Chronic  congestion;  2.  Chronic  congestion 
followed  by  chronic  exudative  nephritis;  3.  Chronic  congestion  fol- 
lowed by  chronic  nephritis  without  exudation;  4.  Chronic  de- 
generation; 5.  Chronic  degeneration  followed  by  chronic  nephritis 
with  exudation;  6.  Chronic  nephritis  with  exudation  not  preceded  by 
congestion;  7.  Chronic  nephritis  without  exudation  not  preceded 
by  congestion. 

Here  are  seven  different  kidney  lesions,  each  one  of  them  fre- 
quently associated  with  cardiac  disease. 

In  bad  cases  of  heart  disease  the  ordinary  symptoms  are :  dysp- 
noea, cough  and  expectoration,  general  dropsy,  vomiting,  headache, 
delirium,  convulsions,  coma,  ansemia,  loss  of  flesh  and  strength. 

It  is  always  difficult  and  often  impossible  in  any  given  case  of 
heart  disease  to  determine  certainly  which  kidney  lesion  exists. 
The  general  rules  which  we  follow  are  these : 

Chrome  Congestion.  — The  cardiac  symptoms  not  as  severe ;  dropsy 
often  present;  the  quantity  of  the  urine  moderately  diminished,  its 
specific  gravity  normal  or  higher  than  normal,  albumin  in  very  small 
quantities,  few  or  no  hyaline  casts. 

Chronic  Congestion  followed  hy  Chronic  Nephritis  ivith  Exudation. — 
The  cardiac  symptoms  more  severe;  the  dropsy  well  marked;  the 
urine  scanty,  its  specific  gravity  normal  or  lowered,  a  large  quantity 
of  albumin,  and  casts  in  variable  number. 

Chronic  Congestion  followed  hy  Chronic  Nephritis  ivithout  Exuda- 
ti/m.—The  patients  are  liable  to  have  attacks  of  contraction  of  the 
arteries.  The  droi>sy  is  not  as  constant.  The  quantity  of  the  urine 
varies,   sometimes  above,  sometimes  below  the  normal.      Its  specific 


44  DELAPIELD — DISEASES   OF  THE   KEDNEYSi 

gravity  is  low.  There  is  but  little  albumin  except  wlien  the  arteries 
are  contracted.     Loss  of  flesh  and  strength  are  marked  features. 

Chronic  Degeneration, — The  cardiac  symptoms. are  severe;  dropsy 
is  regularly  i^resent  but  not  always  marked.  The  quantity  of  the 
urine  varies,  its  specific  gravity  is  unchanged,  there  is  but  little  al- 
bumin. The  patients  are  feeble  and  anaemic  with  a  prolonged  period 
of  scanty  urine,  delirium,  stupor,  and  the  typhoid  state. 

Chronic  Degeneration  followed  hy  Chronic  Nephritis  ivitli  Exuda- 
tion.— The  cardiac  symptoms  are  severe  and  the  dropsy  well  marked. 
The  quantity  of  urine  is  small,  its  specific  gravity  is  rather  high  than 
low.  Albumin  is  present  in  large  quantities,  casts  are  not  so  constant. 
The  patients  are  feeble,  anaemic,  and  get  worse  rapidly. 

Chronic  JVej)hritis  either  icith  or  ivitJiout  Exudation,  not  preceded  hy 
Congestion. — In  these  patients  there  is  the  ordinary  history  of  chronic 
nephritis  lasting  for  months  or  years.  Then,  as  the  endocarditis  ad- 
vances, the  heart's  action  becomes  worse,  the  circulation  is  disturbed, 
and  the  difi'erent  cardiac  symptoms  are  added. 

Treatment. 

Although  we  are  unable  to  remove  the  mechanical  interference 
with  the  circulation,  yet  the  condition  of  the  patients  can  often 
be  very  much  improved.  The  main  indications  are  to  improve  the 
character  of  the  circulation  and  to  remove  the  dropsy.  In  order  to 
improve  the  circulation  it  is  absolutely  necessary  to  study  the  char- 
acter of  the  heart's  action,  to  appreciate  the  organic  changes  in 
the  heart,  and  to  determine  whether  the  walls  of  the  arteries 
are  thickened  and  whether  there  is  an  increase  or  diminution  of 
the  arterial  tension.  It  is  unfortunate  that  there  is  no  instrument 
to  tell  us  certainly  what  the  arterial  tension  is ;  we  have  to  depend 
upon  the  sense  of  touch.  This,  however,  can  be  educated,  and  a  phy- 
sician is  not  competent  to  manage  cardiac  cases  if  he  cannot  appre- 
ciate changes  in  arterial  tension. 

In  many  patients  with  an  irregular  heart,  dyspnoea,  and  dropsy, 
simple  rest  is  of  the  greatest  service.  This  is  especially  marked  in 
hospital  patients  who  have  tried  to  work  up  to  the  time  of  their  ad- 
mission. It  is  often  a  good  rule  to  give  no  medicine  to  such  patients 
until  we  see  how  much  they  improve  with  rest  alone. 

The  regulation  of  the  food  is  of  importance.  It  is  to  be  remem- 
bered that,  while  gastric  indigestion  and  flatulence  make  the  heart's 
action  worse,  on  the  other  hand  meat  is  one  of  the  best  cardiac  stim- 
ulants. Most  patients  are  better  for  meat  in  some  form  at  least  once 
a  day. 


ACUTE   DEGENEEATION   OF  THE   KIDNEYS.  45 

•  Tumultuous  and  exaggerated  heart  action  may  be  due  to  contrac- 
tion of  the  arteries  and  require  such  drugs  as  nitroglycerin  or 
chloral  hydrate.  It  may  be  the  expression  of  a  heart  which  is  really 
feeble  and  rec[uires  digitalis.  It  may  mean  a  real  exaggeration  of  the 
muscular  action  of  the  heart  and  be  benefited  by  aconite,  belladonna, 
and  the  local  action  of  cold.  A  feeble  heart  without  contraction  of 
the  arteries  calls  for  cardiac  stimulants ;  digitalis,  strophanthus,  and 
caffeine  are  the  best.  But  it  is  to  be  remembered  that  with  aortic  and 
mitral  stenosis,  myocarditis,  and  diseased  coronary  arteries,  there 
comes  a  time  when  cardiac  stimulants  make  the  heart's  action  worse 
instead  of  better.  This  is  the  time  for  the  use  of  opium.  Small  doses 
of  codeine  or  of  morphine  give  the  patient  more  relief  than  can  be  ob- 
tained in  any  other  way. 

In  many  patients  the  condition  of  the  heart  and  arteries  varies 
from  day  to  day  so  that  there  have  to  be  many  corresponding  changes 
and  combinations  of  the  drugs — the  cardiac  stimulants,  the  arterial 
dilators,  and  the  opium. 

The  dropsy  is  more  or  less  favorably  affected  by  the  rest  in  bed 
and  the  regulation  of  the  circulation.  It  can  also  be  reduced  by  the 
hot  pack  and  the  hot-air  bath. 

For  very  extensive  cardiac  dropsies,  with  only  chronic  congestion 
of  the  kidney  or  but  little  nephritis,  calomel  is  the  most  efficient  diu- 
retic. Three  grains  of  calomel  with  -5^  of  a  grain  of  morphine,  four 
times  a  day  for  four  days,  is  the  dose.  The  mouth  and  gums  are  to 
be  kept  very  clean.  If  the  drug  acts  properly  there  is  but  little  effect 
on  the  bowels  and  no  salivation,  but  on  the  third  day  the  quantity  of 
urine  increases  and  remains  large  for  several  days.  The  dropsy 
diminishes  and  may  disappear  altogether. 


Acute  Degeneration  of  the  Kidneys. 

Definition. 

An  acute  change  in  the  kidneys,  characterized  by  degeneration  or 
death  of  the  epithelial  cells  of  the  tubules,  to  which  may  be  added 
an  exudation  from  the  blood-vessels. 

Synonyms. — Acute  Bright' s  disease;  Parenchymatous  nephritis; 
Parenchymatous  degeneration. 

Etiology. 

The  introduction  of  certain  poisons  into  the  body  is  regularly  fol- 
lowed by  changes  in  the  cells  of  the  viscera.     The  poisons  which 


46  DELAPIELD — DISEASES  OF  THE  KIDNEYS. 

exert  this  effect  are  ordinarily  mineral  poisons,  sucli  as  arsenic,  mqr- 
cvLi'j,  and  phosphorus;  or  the  poisons  of  infectious  diseases,  such 
as  diphtheria,  typhoid  fever,  etc.  According  to  the  quantity  and 
virulence  of  the  poison  received  into  the  body,  there  are  more  or  less 
marked  changes  produced  in  the  cells  of  the  viscera. 

Small  doses  of  such  poisons,  acting  only  for  a  moderate  length  of 
time,  produce  simj)le  swelling  of  the  cells.  The  cells  are  swollen, 
more  opaque,  more  coarsely  granular.  They  are  not  dead,  nor  broken 
down,  nor  do  they  contain  any  new  substances ;  the  change  in  their 
appearance  is  due  to  the  swelling  of  the  network  which  forms  a  part 
of  every  cell.  Under  these  circumstances  there  are  either  no  changes 
at  all  in  the  blood-vessels  of  the  viscera,  or  a  slight  congestion,  with, 
perhaps,  a  little  exudation  of  serum. 

Larger  doses  of  such  poisons,  or  more  virulent  poisons,  or  a 
longer  duration  of  the  action  of  a  poison,  are  attended  by  the  deposi- 
tion in  the  cell-bodies  of  granules  of  albuminous  matter  and  globules 
of  fat.  At  the  same  time  there  is  a  change  in  the  nutrition  of  the 
cells,  and  they  are  often  broken  and  disintegrated.  Under  these  con- 
ditions there  may  be  considerable  congestion  of  the  vessels  and  an 
exudation  of  serum. 

Yery  large  doses  of  such  poisons  cause  the  death  of  the  cells  of 
the  viscera,  a  death  which  may  take  the  form  of  coagulation-necrosis 
or  of  disintegration  and  breaking  down  of  the  cell.  With  these  changes 
there  will  often  be  an  excessive  congestion  of  the  vessels  and  a  large 
exudation  of  serum. 

As  the  kidneys  are  excreting  organs  it  is  rather  natural  to  think 
that  the  substances  which  cause  degeneration  of  the  renal  epithelium 
do  so  because  they  are  excreted  by  the  kidneys.  But,  as  the  same 
poisons  produce  similar  degeneration  in  many  other  paiis  of  the 
body,  it  seems  more  probable  that  the  effect  of  the  poison  is  produced 
in  the  same  way  that  it  is  in  the  nerves,  the  muscles,  the  liver,  and 
the  spleen. 

The  well-known  fact  that  temporary  cutting  off  of  the  arterial 
blood  from  the  kidneys  in  animals  is  followed  by  degeneration  or 
death  of  the  renal  epithelium,  has  led  to  the  idea  that  degeneration 
of  the  kidneys,  especially  in  cholera,  is  due  to  ischsemia.  This  seems 
possible,  but  it  is  a  theory  not  at  all  applicable  to  most  cases  of  acute 
degeneration. 

It  is  curious  that  so  many  different  poisons  should  act  in  the  same 
way.  There  seems  to  be  nothing  in  common  between  the  poison  of 
corrosive  sublimate  and  that  of  yellow  fever,  and  yet  the  changes  in 
the  kidneys  are  practically  the  same. 

The  inorganic  poisons,  arsenic,  etc.,  act  according  to  the  size  of 


ACUTE  DEGENERATION  OP  THE  KIDNEYS. 


47 


the  dose  taken.  A  small,  dose  produces  only  moderate  degeneration 
of  the  renal  epithelium,  a  large  dose  causes  extensive  necrosis  with 
considerable  exudation  of  blood  serum. 

The  toxines  of  the  different  infectious  diseases  vary  as  to  the  ac- 
tivity of  their  effect  on  the  renal  epithelium,  as  to  the  time  in  the 
disease  when  the  degeneration  takes  place,  and  as  to  the  frequency 
with  which  true  nephritis  is  produced  instead  of  acute  degeneration. 
It  is  a  question  of  much  imi:)ortance  whether  the  same  toxine  produces 


~s^f 


Fig.  2.— Acute  Degeneration  of  the  Kidney.    Phosphorus  Poisoning. 


degeneration  or  nephritis  according  to  its  dose,  or  whether  two  or 
more  different  toxines  are  necessary.  In  scarlatina  and  diphtheria, 
for  example,  the  rule  is  that  acute  degeneration  comes  in  the  early 
days  of  the  disease,  acute  exudative  nephritis  in  the  late  days  of  the 
disease,  and  acute  productive  nephritis  just  after  the  close  of  the  dis- 
ease. Does  this  mean  three  different  toxines,  or  that  the  same  tox- 
ine varies  at  different  stages  of  the  disease,  or  that  the  only  difference 
is  in  the  dose? 

For  clinical  puri)oses  the  recognition  of  the  fact  that  acute  degen- 


48  DELAPIELD— DISEASES  OF  THE  KIDNEYS. 

eration  is  tlie  ordinary  lesion  of  tlie  infectious  diseases  is  of  much 
practical  importance. 

Morbid  Anatomy. 

The  gross  appearance  of  the  kidney  varies  with  the  extent  of  the 
degeneration.  .  In  the  ordinar}^  mild  cases,  such  as  accompany  pneu- 
monia, the  kidney  is  a  little  larger,  the  cortical  portion  a  little  thicker 
and  paler.  In  the  severe  cases,  such  as  accomjiany  acute  yellow 
atroiDhy  of  the  liver,  the  kidney  is  considerably  enlarged  and  more  or 
less  congested. 

The  changes  in  the  renal  epithelial  cells  are:  a  simple  swelling 
of  the  cell  body,  causing  it  to  look  larger  and  more  opaque  and  to 
take  on  irregular  shapes ;  an  infiltration  of  the  cell  bodies  with  gran- 
ules of  albuminoid  matter  and  fat ;  a  death  of  the  cells,  which  may 
take  the  form  of  coagulation  necrosis  or  of  a  disintegration  of  the  cell 
bodies ;  a  desquamation  of  the  dead  cells  so  that  the  tubes  are  filled 
with  them ;  a  formation  of  hyaline  masses  in  the  cells ;  a  growth  of 
new  cells  to  take  the  place  of  the  dead  epithelium.  All  these  changes 
are  most  marked  in  the  convoluted  tubes. 

In  the  kidneys  Avith  extensive  necrosis  of  the  epithelium  there 
may  also  be  congestion  of  the  blood-vessels  and  casts  in  the  tubes. 

Symptoms. 

With  the  severe  acute  degeneration  which  follows  the  ingestion  of 
large  doses  of  arsenic,  mercury,  or  one  of  the  other  inorganic  poisons 
the  urine  is  diminished  in  quantity,  or  suppressed ;  it  contains  albu- 
min, casts,  and  blood ;  its  specific  gravity  is  unchanged.  At  first  the 
general  symptoms  belonging  to  the  j)oison  i)redominate,  but  as  these 
subside  the  patients  continue  to  live  and  suffer  more  or  less  severely 
from  the  degeneration  of  the  kidney.  They  become  feeble,  pass  into 
the  typhoid  state,  and  often  die. 

The  acute  degeneration  which  accompanies  the  infectious  diseases 
such  as  scarlatina,  diphtheria,  tj'phoid  fever,  pneumonia,  etc.,  is  for 
the  most  part  of  mild  type  and  gives  no  symptoms  except  the  pres- 
ence of  a  little  albumin  and  a  few  casts  in  the  urine.  It  is  of  impor- 
tance to  recognize  the  frequency  with  which  this  afi'ection  of  the  kid- 
ney occurs,  the  slight  injury  which  it  inflicts  on  the  patient,  and  the 
completeness  with  which  the  kidney  lesion  disappears  after  the 
recovery  from  the  primary  disease.  Much  unnecessary  anxiety  is 
often  felt  by  physicians  because  in  a  case  of  pneumonia  or  some  other 
infectious  disease  they  find  albumin  and  casts  in  the  urine.  There 
are  fears  not  only  of  death  from  the  primary  disease,  but  of  the  sub- 


CHRONIC  DEGENERATION  OP  THE  KIDNEYS.  49 

sequent  development  of  "  Bright' s  disease. "  If  tlie  albumin  and  casts 
are  due  to  degeneration  of  the  kidneys  anxiety  is  needless.  The 
course  of  the  primary  disease  will  not  be  changed.  If  the  patients 
recover  their  kidneys  return  to  their  normal  condition. 

With  yellow  fever,  with  acute  j^ellow  atrophy  of  the  liver,  and  oc- 
casionally with  the  other  infectious  diseases  the  degeneration  is  of 
intense  type,  with  death  of  a  large  part  of  the  renal  epithelium  and 
exudation  from  the  vessels.  In  such  cases  the  urine  is  scanty  or  sup- 
pressed. It  contains  albumin,  casts,  and  blood.  The  patients  are 
very  ill,  they  may  have  convulsions,  delirium,  or  stupor;  they  often 
die.  But  it  is  hard  to  tell  how  many  of  their  symptoms  are  due  to 
the  complicating  kidney  lesion. 

Treatment. 

So  far  as  the  degeneration  of  the  epithelium  is  concerned,  we 
know  of  no  treatment  which  is  likely  to  affect  it  favorably.  But  in 
the  severe  cases  with  congestion  of  the  kidneys  and  scanty  urine  it 
seems  to  be  good  practice  to  use  the  hot-air  bath  or  the  hot  pack. 

It  is  evident  that  acute  degeneration  of  the  kidney  can  be  sharply 
distinguished  from  all  other  forms  of  kidney  disease.  It  is  always 
produced  by  the  introduction  of  some  poison  into  the  body.  It  is 
not  accompanied  by  dropsy,  contraction  of  the  arteries,  or  by  other 
renal  symptoms.  It  is  not  usually  dangerous  to  life.  It  is  a  tempo- 
rary condition  not  followed  by  any  chronic  kidney  disease.  If  the 
patient  recovers  from  his  poisoning  the  kidneys  return  to  their  nor- 
mal condition. 

Chronic  Degeneration  of  the  Kidneys. 

Definition. 

A  chronic  disease  of  the  kidneys  characterized  by  degenerative 
changes  in  the  renal  epithelium. 

Synonyms. — Chronic  Bright' s  disease.  Chronic  parenchymatous 
nephritis,  Fatty  kidney. 

Etiology. 

The  same  mechanical  obstructions  to  the  circulation — heart  dis- 
ease, pleuritic  effusions,  etc. — which  produce  chronic  congestion,  can, 
instead  of  this,  produce  chronic  degeneration  of  the  kidney. 

It  is  said  that  anaemia  of  the  kidneys  produces  degeneration  of 
the  renal  ejuthelium.  Exi)eriments  iij)on  animals  show  that  this  view 
is  theoretically  possible.  It  may  l)e  that  the  degeneration  of  the 
Vol.  L— 4 


50  DELAPIELD — DISEASES   OF  THE   KIDNEYS. 

kidneys  seen  in  old  and  feeble  persons  is  due  to  a  diminislied  blood 
supply,  but  we  can  hardly  speak  with  certainty  on  this  point. 

Chronic  diseases,  such  as  phthisis  and  cancer,  are  followed  by 
chronic  degeneration  of  the  kidneys. 

There  is  a  group  of  cases  in  which,  although  the  health  of  the  pa- 
tients is  not  good,  it  is  not  easy  to  fix  on  a  definite  cause  for  the 
chronic  degeneration. 

Apparently  many  of  the  authors  who  describe  a  "  chronic  paren- 
chymatous nephritis"  include  under  this  head  both  chronic  degener- 
ation and  chronic  nephritis. 

The  matter  is  further  complicated  by  the  fact  that  kidneys  may 
be  in  the  condition  of  chronic  degeneration  for  some  time  and  then 
become  further  altered  by  a  chronic  nephritis  with  exudation,  and  by 
waxy  degeneration  of  the  glomeruli. 

MOEBID  AjSTATOMY. 

If  the  degeneration  follows  heart  disease  the  kidneys  are  large, 
weighing  together  from  sixteen  to  twenty  ounces.  Their  surfaces  are 
smooth ;  the  cortical  portion  is  thickened,  of  pink  or  white  color,  the 
pyramids  are  red.  The  gross  appearance  is  that  of  the  so-called  large 
white  kidney.  The  epithelium  of  the  cortex  tubes  is  swollen  and 
coarsely  granular.  The  capillaries  of  the  glomeruli  are  dilated, 
with  more  or  less  thickening  of  their  walls.  The  veins  in  the  pyra- 
mid are  congested.  There  are  no  changes  in  the  stroma,  or  in  the 
arteries. 

If  the  degeneration  follows  phthisis,  cancer,  or  any  wasting 
disease,  the  kidneys  are  usually  large,  with  a  white  or  yellowish 
cortex.  There  are  no  changes  except  in  the  cortex  tubes.  In  these 
the  epithelial  cells  are  either  coarsely  granular,  or  infiltrated  with 
fat. 

If  the  degeneration  occurs  in  old  people,  or  without  discoverable 
cause,  the  kidneys  may  be  either  large  and  white,  or  of  the  size  and 
appearance  of  a  normal  kidney,  or  small  and  red.  There  are  the 
same  degenerative  changes  in  the  epithelium  of  the  cortex  tubes,  with 
no  lesions  in  the  stroma  or  the  glomeruli. 

Symptoms. 

With  the  degeneration  caused  by  heart  disease  the  quantity  of 
the  urine  varies  with  the  changes  in  the  action  of  the  heart  and  the 
contraction  of  the  arteries,  sometimes  abundant,  sometimes  scanty, 
sometimes  suppressed.     The  specific  gravity  is  not  diminished,  nor 


CHRONIC  DEGENERATION  OF  THE   KIDNEYS.  51 

is  the  proportion  of  urea  to  the  ounce  diminished.  Albumin  and 
casts  in  small  quantities  are  more  frequently  present  than  with  chronic 
congestion.  While  it  is  difficult  to  separate  the  kidney  symptoms 
from  the  heart  symptoms,  yet  one  has  the  impression  that  this  kid- 
ney lesion  is  more  serious  than  chronic  congestion  and  has  its  effect 
in  increasing  the  loss  of  nutrition  and  the  anaemia. 

If  the  degeneration  is  followed  by  chronic  nephritis  with  exuda- 
tion albumin  appears  in  the  urine  in  large  quantities ;  the  ansemia 
and  dropsy  are  very  marked,  and  the  patients  get  worse  rapidly. 

When  the  degeneration  accompanies  chronic  diseases,  such  as 
phthisis  or  cancer,  the  urine  remains  normal,  or  from  time  to  time 
contains  a  little  albumin  and  a  few  casts.  The  patients  are  so  ill 
with  their  primary  disease  that  the  secondary  degeneration  of  the  kid- 
neys is  hardly  appreciable  during  life. 

The  group  of  cases  in  which  the  degeneration  occurs  without  dis- 
coverable cause  is  interesting,  for  the  kidney  lesion  may  be  the  cause 
of  death.  It  is  a  difficult  group  to  study,  because  the  cases  are  not 
very  numerous,  and  the  clinical  histories  and  autopsies  are  apt  to  be 
dissociated.  The  autopsies  are  for  the  most  part  in  hospital  patients 
with  short  and  imperfect  histories ;  while  the  clinical  histories  are  of 
private  patients  on  whom  it  is  difficult  to  obtain  autopsies.  I  think, 
however,  it  can  be  said  that  the  urine  remains  normal,  or  from  time 
to  time  contains  a  little  albumin  and  few  casts,  and  that  neither 
dropsy,  nor  a  pulse  of  high  tension,  nor  an  hypertrophied  left  ven- 
tricle, nor  acute  ursemic  symptoms  are  present. 

The  patients  gradually,  month  after  month,  lose  flesh  and  strength 
and  become  more  or  less  anaemic .  They  may  have  a  variety  of 
digestive  disturbances.  The  course  of  the  disease  is  slow,  sometimes 
interrupted  by  periods  of  improvement,  but  regularly  getting  worse 
from  year  to  year.  Finally  the  patients  are  so  feeble  that  they  re- 
main in  bed;  they  develop  alternating  delirium  and  stupor,  and  so 
die. 

The  diagnosis  in  these  cases  is  extremely  difficult.  They  resem- 
ble cases  of  malignant  disease  in  which  no  tumor  can  be  found,  and 
cases  of  chronic  nephritis  with  normal  urine  and  no  changes  in  the 
heart  or  arteries. 

Treatment. 

It  is  not  easy  to  find  means  to  influence  chronic  degeneration  of 
the  renal  epithelium.  The  best  that  we  can  do  for  the  patients  is  to 
stop  all  vicious  hal)its,  to  regulate  the  diet  and  mode  of  life,  and  to 
relieve  the  disturl)ances  of  circulation. 


52  DELAFIELD — DISEASES   OF  THE  KIDNEYS. 

Acute  Exudative  Nephritis. 

Definition. 

An  acute  inflammation  of  the  kidneys,  cliaracterized  by  conges- 
tion, exudations  of  the  blood  plasma,  emigration  of  white  blood-cells, 
diapedesis  of  red  blood-cells,  to  which  may  be  added  changes  in  the 
renal  epithelium  and  in  the  glomeruli. 

Synonyms. — Acute  Bright's  disease;  Parenchymatous  nephritis; 
Tubal  nephritis;  Desquamative  nephritis;  Catarrhal  nephritis; 
Croupous  nephritis;  Glomerulo-nephritis. 

Etiology. 

Acute  exudative  nephritis  is  frequently  a  primary  inflammation, 
occurring  either  after  exposure  to  cold  or  without  discoverable  cause. 
It  may  complicate  any  one  of  the  infectious  inflammations  or  diseases, 
but  is  especially  common  with  scarlet  fever.  It  is  one  of  the  forms 
of  nephritis  which  are  caused  by  pregnancy. 

Acute  exudative  inflammation  in  any  part  of  the  body  seems  to 
be  caused  by  local  irritation,  by  the  presence  of  irritating  substances 
in  the  blood,  and  by  changes  in  the  circulation  of  the  blood  in  the  in- 
flamed portion  of  the  body.  Pathogenic  bacteria  are  sometimes 
present,  sometimes  absent  in  the  inflamed  tissue. 

Unquestionably  all  the  infectious  diseases  are  often  complicated 
with  inflammations  of  different  parts  of  the  body.  The  probable 
causes  of  these  are  the  chemical  poisons  produced  by  the  growth  of 
the  pathogenic  bacteria  belonging  to  each  disease.  It  seems  also 
that  the  poison  of  each  disease  has  a  preference  for  particular  por- 
tions of  the  body.  In  rheumatism  the  joints  and  heart  are  regularly 
inflamed ;  in  measles,  the  bronchi ;  in  scarlet  fever  and  diphtheria 
the  throat  and  the  kidneys. 

As  regards  the  presence  of  bacteria  in  the  kidneys  themselves  as 
exciting  causes  of  inflammation  our  knowledge  is  uncertain. 

AVhether  nephritis  in  puerperal  women  and  after  exposure  to  cold 
is  due  to  disturbances  of  circulation  or  to  some  poison  in  the  blood  is 
not  certain. 

There  are  marked  differences  in  the  severity  of  different  cases  of 
nephritis.  The  exudation  of  serum  is  larger  in  one  case,  the  emi- 
gration of  white  blood-cells  in  another.  In  one  kidney  the  epithelial 
cells  are  contracted,  in  another  they  are  swollen  and  degenerated. 
The  glomeruli  are  much  more  changed  in  some  kidneys  than  in  others. 
How  closely  these  differences  in  the  lesions  correspond  to  differences 
in  the  causation  of  the  nephritis  we  do  not  know. 


ACUTE   EXUDATIVE   NEPHKITIS. 


53 


MoKBiD  Anatomy. 

In  a  nephritis  of  this  type  we  should  expect  that  the  inflammatory- 
products,  the  serum,  white  and  red  blood-cells,  and  coagulable  mat- 
ter from  the  blood-plasma,  would  collect  in  the  Malpighian  bodies 
and  tubes,  or  infiltrate  the  stroma  between  the  tubes ;  and  that  of  the 
inflammatory  products  in  the  tubes  and  Malpighian  bodies,  a  part 
would  be  discharged  with  the  urine  and  a  part  be  found  in  the  kidney 
after  death.  We  should  also  expect  that  the  quantity  of  inflamma- 
tory products  would  be  in  i^roportion  to  the  severity  of  the  inflamma- 


FiG.  3.— Cortex  Tubes.    Acute  Exudative  Nephritis. 

tion,  and  that  an  excessive  number  of  pus-cells  would  belong  to  the 
especially  severe  forms  of  the  disease.  Still  further,  it  is  evident  that 
Avith  the  milder  examples  of  nephritis,  with  but  little  exudation,  no 
inflammatory  products  might  be  found  in  the  kidney  after  death,  all 
having  been  discharged  into  the  urine  during  life. 

As  a  matter  of  fact,  the  kidneys  do  present  just  such  changes. 
In  the  mild  cases  we  find  no  decided  lesions  in  the  kidnev  after  death. 


54 


DELAPIELD — DISEASES   OF  THE   KIDNEYS. 


In  the  more  severe  cases  the  kidneys  are  increased  in  size,  their 
surfaces  are  smooth,  the  cortical  portion  is  thick  and  white,  or  white 
mottled  with  red,  or  the  entire  kidney  is  intensely  congested.  If  the 
stroma  is  inj&ltrated  with  serum,  the  kidney  is  succulent  and  wet;  if 
the  number  of  pus-cells  is  very  great,  there  will  be  little  whitish  foci 
in  the  cortex. 

In  such  kidneys  we  find  the  evidence  of  exudative  inflammation  in 


Fig.  4. — Cortex  Tubes.    Acute  Exudative  Nephritis. 

the  tubes,  the  stroma,  and  the  glomeruli,  all  the  changes  being  most 
marked  in  the  cortical  portion  of  the  kidney. 

The  epithelium  of  the  convoluted  tubes  is  often  simply  flattened. 
As  this  same  appearance  is  also  found  in  the  chronic  congestion  of 
heart  disease,  it  seems  probable  that  this  change  of  the  shape  of  the 
cells  is  merely  due  to  the  inflammatory  congestion. 

In  other  cases,  not  only  is  the  epithelium  flattened  but  there  is 
also  a  real  dilatation  of  the  cortex-tubes.  This  dilatation  involves 
groups  of  tubes,  or  all  the  cortex-tubes  uniformly. 

In  other  cases,  the  epithelium  of  the  convoluted  tubes  is  swollen, 
opaque,  degenerated,  and  detached  from  the  tubes. 


ACUTE   EXUDATIVE   NEPHRITIS.  55 

The  tubes,  whether  with  flattened  epithelium  or  dilated,  ma;y  be 
empty.  More  frequently,  however,  they  contain  coagulated  matter 
in  the  form  of  irregular  masses  and  of  hyaline  cylinders.  The  irregu- 
lar masses  are  found  principally  in  the  convoluted  tubes ;  they  seem 
to  be  formed  by  a  coagulation  of  substances  contained  in  the  exuded 
blood-plasma,  and  are  not  to  be  confounded  with  the  hyaline  globules 
so  often  found  in  normal  convoluted  tubes.  The  cylinders  are  more 
numerous  in  the  straight  tubes,  but  are  also  found  in  the  convoluted 
tubes.  They  also  are  evidently  formed  of  matter  coagulated  from 
the  exuded  blood-plasma,  and  are  identical  with  the  casts  found  in 
the  urine. 

The  tubes  may  also  contain  red  and  white  blood-cells. 

In  the  cases  in  which  there  is  an  excessive  emigration  of  white 
blood-cells,  we  find  these  cells  in  the  tubes,  in  the  stroma,  or  distend- 
ing the  capillary  veins.  This  excessive  emigration  is  not  necessarily 
attended  with  exudation  of  the  blood-serum,  and  so  the  urine  of  these 
patients  may  contain  no  albumin.  The  white  blood-cells  are  not 
usually  found  equally  diffused  through  the  kidnej^s,  but  are  collected 
in  foci  in  the  cortex.  These  foci  may  be  very  minute,  or  may  attain 
a  considerable  size. 

The  glomeruli  regularly  are  changed.  The  cavities  of  the  cap- 
sules may  contain  coagulated  matter  and  white  and  red  blood-cells, 
just  as  do  the  tubes.  The  capsular  epithelium  may  be  swollen,  some- 
times so  much  so  as  to  resemble  the  tubular  epithelium,  and  this 
change  is  most  marked  in  the  capsular  epithelium  near  the  entrance 
of  the  tubes. 

The  most  noticeable  change,  however,  is  in  the  capillary  tufts  of 
the  glomeruli.  These  capillaries  are  normally  covered  on  their  outer 
surface  by  flat,  nucleated  cells,  so  that  the  tuft  is  not  made  up  of 
naked  capillaries,  but  each  separate  capillary  throughout  its  entire 
length  is  covered  over  with  these  cells.  There  are  also  flat  cells 
which  line  the  inner  surfaces  of  the  capillaries,  although  not  uni- 
formly, as  is  the  case  in  capillaries  in  other  parts  of  the  body.  Still, 
in  spite  of  the  presence  of  all  these  cells,  the  outlines  of  the  walls  of 
the  capillaries  are  fairly  distinct. 

In  exudative  nephritis  the  swelling  and  growth  of  cells  on  and  in 
the  capillaries  change  the  appearance  of  the  glomeruli.  They  are 
larger,  more  opaque,  the  outlines  of  the  main  divisions  of  the  tuft 
are  visible,  but  those  of  the  individual  capillaries  are  lost. 

It  is  difficult  to  tell  how  much  these  changes  in  the  glomeruli  in- 
terfere with  the  passage  of  the  blood  through  their  capillaries. 

In  most  cases  of  exudative  nephritis  the  patients  recover,  and  the 
glomeruli  return  to  their  natural  condition. 


56 


DELAITELD — DISEASES   OF  THE   KIDNEYS. 


In  some  examples  of  exudative  nephritis  we  also  find  a  thickening 
of  the  walls  of  the  branches  of  the  renal  artery  within  the  kidney. 
This  thickening  is  principally  due  to  a  swelling  of  the  muscle-cells  in 
the  walls  of  these  vessels. 

All  these  changes  in  the  kidneys  are  of  such  a  character  that  they 
are  not  likely  to  be  followed  by  a  chronic  nephritis.     On  the  con- 


FiG.  5.— A  Glomerulus.     Acute  Exudative  Nephritis. 

trary,  after  the  patients  have  recovered,  the  kidneys  return  to  their 
normal  condition. 


Symptoms. 

1.  There  are  cases  of  acute  nephritis  of  so  mild  a  character  that 
they  may  easily  be  overlooked.  I  think  that  these  mild  cases  occur 
more  frequently  than  is  commonly  supposed.  The  patients  are 
hardly  sick  enough  to  go  to  bed.  They  have  a  little  headache,  per- 
haps some  aching  in  the  back  and  limbs,  loss  of  appetite,  a  little  nau- 
sea, and  the  feeling  of  general  malaise.     They  often  think  that  they 


ACUTE  EXUDATR^  NEPHRITIS.  57 

have  taken  cold.  These  indefinite  symptoms  last  for  one  or  two 
weeks,  disappear,  and  the  patient  is  well  again.  If  the  urine  is  not 
examined  it  is  not  known  that  the  patient  has  been  suifering  from  a 
mild  nephritis.  If  the  urine  is  examined  it  is  found  that  the  quantity 
is  somewhat  diminished,  the  specific  gravity  is  not  lowered,  an  ap- 
preciable quantity  of  albumin  is  jiresent,  with  hyaline,  granular,  and 
epithelial  casts,  sometimes  with  red  and  white  blood-cells.  If  the 
number  of  blood-cells  is  sufficient  to  color  the  urine,  the  patient's  at- 
tention is  attracted  by  the  change  in  color ;  the  diminished  quantity 
he  is  apt  not  to  notice.  These  changes  in  the  urine  last  for  four  or 
five  weeks  and  then  disappear. 

2.  The  ordinary  cases  of  acute  exudative  nephritis  vary  indeed  in 
their  severity,  but  all  give  characteristic  symptoms.  The  only  dis- 
eases with  which  they  can  be  confounded  are  acute  productive  ne- 
phritis, and  exacerbations  of  a  chronic  nephritis.  If  any  person 
seems  to  have  several  attacks  of  acute  nephritis,  it  regularly  means 
that  he  has  a  chronic  nephritis  with  exacerbations. 

The  quantity  of  urine  is  diminished  at  the  onset  of  the  nephritis 
and  continues  small  until  the  activity  of  the  inflammation  has  sub- 
sided ;  then  the  quantity  increases  from  day  to  day  and  may  even  ex- 
ceed the  normal.  The  quantity  of  the  urine  must  be  in  proportion 
to  the  quantity  of  blood  which  passes  through  the  kidneys,  so  that 
this  quantity  gives  us  a  measure  of  the  intensity  of  the  congestion 
which  is  arresting  the  circulation  of  the  blood  through  the  kidney. 
Complete  suppression  of  urine  is  a  serious  symptom,  both  because  it 
denotes  an  intense  nephritis  and  because  it  is  of  itself  a  cause  of 
death.  The  production  of  only  a  few  ounces  of  urine  in  each  twenty - 
four  hours  is  the  rule  in  a  great  number  of  cases,  and  is  not  neces- 
sarily of  serious  import.  If  it  lasts  only  a  few  days  the  patients  do 
Ijerfectly  well.  If  the  scanty  excretion  of  urine  is  kept  up  for  a  num- 
ber of  days,  opinions  vary  as  to  the  results.  Some  believe  that  the 
diminished  quantity  of  urine  is  the  cause  of  the  dropsy.  Some  think 
that  the  deficient  excretion  of  excrementitious  substances  causes  the 
convulsions.  Some  believe  that  the  principal  effect  of  a  diminished 
excretion  of  urine  is  to  cause  bodily  feebleness. 

Unquestionably  the  production  of  urine  may  be  very  small  for  a 
number  of  days  and  yet  the  patients  do  well.  Dr.  Whitelaw  {Lancet, 
Sept.  29,  1877)  reports  a  case  of  anuria  lasting  for  twenty-five  days. 
The  patient  was  a  boy  eight  years  old.  The  suppression  of  urine 
began  twelve  weeks  after  the  beginning  of  a  scarlet  fever.  With  the 
exception  of  two  ounces  passed  on  the  thirteenth  day,  there  was  com- 
plete anuria  for  twenty-five  days.  Except  for  slight,  headaches  and 
later  slight  oedema,  there  were  no  ura3mic  or  dropsical  symptoms 


58  DELAFIELD — DISEASES  OF  THE  KIDNEYS. 

tliroughout.  Tliere  was  no  albuminuria  and  no  fever.  The  boy  was 
watched  night  and  day.     He  recovered  entirely. 

The  specific  gravity  of  the  urine  remains  normal  or  is  higher 
while  the  quantity  is  small ;  when  the  quantity  is  increased  the  speci- 
fic gra-sdty  falls  a  little. 

The  appearance  of  the  urine  is  turbid,  or  smoke-colored,  or 
bloody. 

Albumin  is  present  in  very  large  quantities.  Casts  are  numerous — 
hyaline,  granular,  nucleated,  epithelial,  and  blood.  There  are  also 
red  and  white  blood-cells,  and  epithelial  cells  from  the  kidneys 
and  from  the  bladder.  As  a  rule  the  quantity  of  albumin  and  the 
number  of  casts  are  in  jjroportion  to  the  severity  of  the  nephritis, 
but  this  is  not  always  the  case.  Large  quantities  of  albumin, 
numerous  casts,  and  many  red  and  white  blood-cells  may  be  found  in 
the  urine  of  kidneys  which,  after  death,  show  no  structural  changes 
except  in  the  glomeruli ;  while,  on  the  other  hand,  small  quantities 
of  albumin  and  a  few  hyaline  casts  are  compatible  with  a  severe  ne- 
phritis. Still  further,  the  number  of- casts  found  in  the  urine  during 
life  is  not  always  in  proportion  to  the  number  of  casts  found  in  the 
corresponding  kidneys  after  death. 

The  characteristic  symptoms  of  acute  exudative  nephritis  are :  a 
febrile  movement,  with  more  or  less  prostration;  headache,  stupor, 
sleeplessness,  restlessness,  muscular  twitching,  general  convulsions; 
dyspnoea,  loss  of  appetite,  nausea  and  vomiting;  a  pulse  of  high  ten- 
sion with  exaggerated  heart  action,  or  hypertrophy  of  the  left  ventri- 
cle ;  dropsy  and  anaemia. 

When  acute  nephritis  complicates  scarlet  fever  or  one  of  the  other 
infectious  diseases,  the  patient  may  already  have  a  febrile  movement 
belonging  to  the  primary  disease.  If  the  nephritis  is  primary,  or  if 
it  is  not  developed  until  the  fever  belonging  to  the  original  disease 
has  subsided,  there  is  a  rise  of  temperature  belonging  to  the  nephritis. 
This  fever  is  in  proportion  to  the  severity  of  the  nephritis,  and  in 
children  is  sometimes  as  high  as  105°  F.  The  fever,  however,  does 
not  usually  continue  more  than  a  week,  although  the  nephritis  lasts 
longer. 

Headache,  restlessness,  sleeplessness,  delirium,  and  stupor  during 
the  first  days  of  an  acute  nephritis  seem  to  be  of  the  same  nature  as 
they  are  in  so  many  severe  inflammations  attenaed  with  fever.  But 
later  in  the  disease,  after  the  temperature  has  fallen,  they  apparently 
depend  upon  the  increased  tension  in  the  arteries.  In  the  cases  of 
prolonged  anuria,  however,  there  is  a  condition  of  mild  delirium  and 
stupor  with  a  soft  pulse. 

General  convulsions  are  of  not  uncommon  occurrence,  especially  in 


ACUTE   EXUDATIVE   NEPHEITIS.  59 

children.  They  do  not  usually  occur  until  after  the  nephritis  has 
existed  for  several  days.  They  are  often  preceded  by  involuntary 
contractions  of  groups  of  muscles.  They  may  be  preceded  and  fol- 
lowed by  stupor.  The  frequency  of  their  occurrence  does  not  seem  to 
be  in  direct  relation  to  the  quantity  of  urine  excreted.  They  may  be 
absent  in  fatal  anuria,  and  present  when  the  quantity  of  urine  is 
nearly  normal.  It  is  the  rule  before  and  during  the  convulsions  to 
have  a  marked  increase  in  the  tension  of  the  jjulse.  While  general 
convulsions  are  an  alarming  symptom,  yet  a  great  many  children 
make  a  very  good  recovery  after  having  them. 

Loss  of  appetite,  nausea,  and  vomiting  at  the  beginning  of  the  ne- 
phritis seem  to  be  due  to  the  febrile  movement.  Later  in  the  disease 
it  is  probable  that  they  are  due  to  the  disturbance  of  the  function  of 
the  kidneys. 

A  pulse  of  high  tension,  exaggerated  contractions  of  the  heart,  and 
sometimes  hypertrophy  of  the  left  ventricle  are  present  in  some  of  the 
cases,  not  by  any  means  in  all  of  them.  This  disturbance  of  the 
circulation  is  evidently  caused  by  contraction  of  the  arteries.  That 
the  contraction  of  the  arteries  is  due  to  the  presence  of  irritating  sub- 
stances in  the  blood  is  probable,  but  not  certain. 

Dropsy  is  present  in  many  of  the  cases.  It  is  usually  confined  to 
the  subcutaneous  connective  tissue.  Its  probable  causes  have  already 
been  discussed. 

Anaemia,  with  a  pallor  of  the  skin  out  of  proportion  to  the  dimi- 
nution in  the  quantity  of  hsemoglobin,  is  very  often  seen.  We  are 
still  ignorant  as  to  the  way  in  which  an  acute  nephritis  causes  such 
changes  in  the  composition  of  the  blood. 

3.  Acute  exudative  nephritis  with  an  excessive  production  of  pus 
cells.  This  is  not  to  be  confounded  with  embolic  nephritis,  nor  with 
nephritis  caused  by  cystitis.  It  is  only  a  severe  variety  of  acute  ex- 
udative nephritis.  It  is  seen  both  in  children  and  in  adults.  I  have 
seen  it  with  scarlatina,  dijjhtheria,  and  measles,  and  occurring  with- 
out discoverable  cause. 

The  invasion  is  sudden,  with  a  high  temperature  and  marked 
I)rostration.  Restlessness,  headache,  delirium,  and  stujjor  are  soon 
developed  and  continue  throughout  the  disease.  The  patients  rapidly 
lose  flesh  and  strength  and  pass  into  the  typhoid  state.  Dropsy  is 
slight,  or  absent  altogether.  The  urine  is  not  so  much  diminished 
in  quantity  as  one  would  expect.  Its  specific  gravity  is  not  changed. 
Albumin,  casts,  and  red  and  white  blood-cells  are  present  in  consid- 
erable quantities,  but  not  always  early  in  the  disease,  and  they  may 
even  be  absent  altogether. 

Although  this  form  of  nei)hritis  is  not  of  common  occurrence,  the 


60  DELAJFIELD — DISEASES   OF  THE   KIDNEYS. 

"Uimsual  character  of  the  symptoms  and  the  great  mortality  are  rea- 
sons for  calling  special  attention  to  it.  It  differs  from  the  ordinary 
form  of  exudative  nephritis  in  that  it  behaves  like  an  infectious  in- 
flammation, and  that,  although  the  emigration  of  white  blood-cells 
is  large,  the  exudation  of  serum  may  be  small,  and  so  the  urine  may 
show  but  little  change.  It  is  probable  that  the  nephritis  is  the  re- 
sult of  some  obscure  form  of  bacteritic  infection. 

The  ordinary  duration  of  an  acute  exudative  nephritis,  which  ter- 
minates favorably,  is  about  four  weeks,  but  may  extend  to  eight. 
The  recovery  is  a  complete  one,  and  there  is  no  danger  that  chronic 
nephritis  will  follow. 

Peogxosis. 

The  patients,  who  for  three  or  four  weeks  have  only  the  fever, 
prostration,  loss  of  appetite,  nausea,  anaemia,  dropsy,  and  changes  in 
the  urine,  as  a  rule  recover  completely  and  are  not  at  any  time  in  real 
danger. 

The  development  of  the  cerebral  sj^mptoms — the  stupor,  head- 
ache, sleeplessnes,  restlessness, ,  and  general  con^Tilsions — always 
causes  anxiety,  but  yet  even  of  these  patients  the  larger  number  get 
entirely  well.  The  cases  with  an  excessive  production  of  pus-cells 
differ  from  all  the  other  forms  of  acute  exudative  nephritis,  and  are 
very  fatal. 

Treatsient. 

We  have  to  treat  an  acute  exudative  inflammation  of  the  kidneys, 
which  naturally  runs  its  course  in  four  weeks  and  terminates  in  re- 
cover3\  We  have  also  to  treat  the  sj^mptoms  of  this  nephritis — 
the  scanty  urine,  dropsy,  vomiting,  anaemia,  and  cerebral  symptoms. 
We  have  to  treat  these  conditions  more  frequently  in  children  than 
in  adults,  and  very  often  as  compHcating  an  infectious  disease. 

The  most  efficient  treatment  of  the  nephritis  is  the  application  of 
heat  to  the  entire  surface  of  the  body.  This  can  be  done  in  a  number 
of  ways,  but  the  best  way  is  to  wrap  the  entire  body  in  a  blanket 
wrung  out  of  hot  water.  Such  a  hot  pack  can  be  used  for  an  hour  at 
a  time  once  or  twice  a  day.  Of  drugs  the  most  reliable  is  aconite — 
one  or  two  minims  of  the  tincture  every  hour.  It  may  be  necessary  to 
precede  the  aconite  by  giving  one  drachm  of  sulphate  of  magnesia 
every  hour  until  the  bowels  move,  or  until  eight  doses  have  been 
taken.  There  are  cases,  in  which  the  nephritis  is  not  of  very  acute 
type,  where  digitalis  seems  to  exert  a  favorable  effect  on  thQ  circula- 
tion. The  preferable  form  of  the  di'ug  is  digitalin  in  doses  of  one 
one-hundredth  of  a  grain. 


ACUTE  EXUDATIVE  NEPHRITIS.  61 

The  scanty  urine  often  causes  anxiety.  Of  course  it  is  better  tliat 
the  patients  should  pass  a  fair  quantity  of  urine,  but  I  think  that 
there  is  a  tendency  to  exaggerate  the  dangers  of  scanty  urine  and  to 
be  too  energetic  in  giving  diuretics.  As  the  diminution  in  the  quan- 
tity of  urine  is  due  to  the  congestion  of  the  kidneys,  if  we  can  de- 
crease the  congestion  the  urine  will  increase.  The  best  way  to  do 
this  is  to  apply  heat  to  the  surface  of  the  body.  The  use  of  diuretics 
is  to  be  avoided.  The  attempts  to  make  up  for  the  scanty  production 
of  urine  by  purging  or  sweating  the  patient  have  never  seemed  to 
me  to  be  of  any  practical  use. 

The  febrile  movement  in  an  acute  nephritis  requires  no  treatment. 

The  prostration,  loss  of  appetite,  nausea,  and  vomiting  only  call 
for  rest  in  bed  and  a  fluid  diet. 

The  anaemia  ought  to  be  jjrevented  or  relieved,  but,  while  the  ne- 
phritis is  still  active,  I  know  of  no  way  in  which  this  can  be  done. 
Wlien  convalescence  is  established  then  the  anaemia  readily  improves 
with  the  ordinary  methods  of  treatment. 

The  dropsy  is  subcutaneous,  and  even  when  considerable,  does  lit- 
tle harm.  It  disappears  of  itself  as  the  nephritis  subsides.  The 
rest  in  bed  and  the  hot  pack  are  all  the  treatment  necessary  for  it. 
To  give  diuretics  or  cathartics  to  get  rid  of  the  dropsy  is  quite  use- 
less. 

The  cerebral  symptoms  are  the  ones  to  which  most  attention  has 
been  directed.  There  can  be  no  question  that  they  accompany  a  con- 
traction of  the  arteries  with  increased  arterial  tension  and  labored 
action  of  the  heart.  No  matter  what  views  one  may  entertain  as  to 
the  cause  of  this  change  in  the  circulation,  I  believe  that  treatment  is 
best  directed  to  the  arteries  themselves,  rather  than  to  the  uncertain 
causes  of  their  contraction.  Fortunately  there  are  drugs  which  stop 
contraction  of  the  arteries  promptly  and  efficiently.  Of  these  drugs 
the  most  suitable  are:  aconite,  nitroglycerin,  chloral  hydrate,  and 
opium,  preferably  given  in  small  doses  and  at  regular  intervals  be- 
fore the  cerebral  symi)toms  are  marked,  but  in  large  doses  hyjjoder- 
mically  or  by  the  rectum  to  stop  a  severe  attack. 

It  is  wise  to  watch  the  condition  of  the  heart  and  arteries,  and,  as 
soon  as  increased  arterial  tension  is  developed,  not  to  wait  for  the 
manifestation  of  the  cerebral  symi)toms,  but  to  try  to  relieve  it  at  once. 

The  way  in  which  we  manage  the  patients,  therefore,  is  as  follows : 
They  are  put  to  bed  or  kept  in  the  house  until  the  nephritis  has  run 
its  course.  They  are  put  on  a  fluid  diet,  preferably  milk,  and  the 
skin  of  the  entire  body  is  cleaned  once  a  day.  For  many  cases  no 
other  treatment  is  necessary. 

If  vomiting  is  troublesome  it  can  usually  be  controlled  by  adding 


62  DELAPEELD — DISEASES  OF  THE   KIDNEYS. 

oxalate  of  cerium  and  bicarbonate  of  soda  to  tlie  milk.  For  the  rest- 
lessness and  sleeplessness  cMoral  hydrate,  the  bromides,  or  opium 
may  be  employed. 

If  the  nephritis  is  of  severe  type  the  patient  is  T\T:apped  in  a 
blanket  wrung  out  of  hot  water  and  kept  in  it  for  one  hour  either 
once  or  twice  every  day.  In  addition  we  give  one  drachm  of  sulphate 
of  magnesia  every  hour  until  the  patient  has  taken  eight  doses  or  the 
bowels  begin  to  move.  This  is  followed  by  one  or  two  minims  of 
tincture  of  aconite  every  hour. 

Throughout  the  disease  we  watch  the  pulse,  and  as  soon  as  it 
shows  any  increased  tension  give  chloral  hydrate  in  doses  of  from 
two  to  five  grains  every  three  hours. 

If  severe  headache,  muscular  twitchings,  or  general  convulsions 
occur,  to  most  of  the  patients  we  give  chloral  hydrate  in  doses  of 
from  5  to  20  grains  by  the  rectum,  or  nitroglycerin  in  doses  of  from 
yIq-  to  -V  of  a  grain  hypodermically,  or  morphine  in  doses  of  from 
yV  to  ^  of  a  grain  hypodermically.  In  strong  and  robust  adults  with 
a  good  deal  of  venous  congestion  general  blood-letting  may  be  advisa- 
ble. For  the  relief  of  the  convulsions  urethane  in  solution,  given  in 
repeated  doses  up  to  100  grains  in  twenty-four  hours,  is  said  to  be  of 
service. 

As  the  nephritis  subsides  the  milk  is  gradually  replaced  by  solid 
food,  and  iron  and  oxygen  are  given. 

Acute  Productive  (or  Diffuse)  Nephritis. 
Definitign. 

An  acute  inflammation  of  the  kidneys,  characterized  by  exudation 
from  the  blood-vessels,  a  groT\i;h  of  new  connective  tissue  in  the 
stroma,  and  changes  in  the  epithelium  and  the  glomeruli. 

Synomjms. — Acute  Bright' s  disease;  Parenchymatous  nephritis; 
Croupous  nephritis ;  Glomerulo-nephritis. 

Etiology. 

This  is  the  most  serious  and  important  of  the  forms  of  acute  ne- 
phritis for  the  reason  that  its  lesions  are  from  the  first  of  a  permanent 
character.  It  does  not  follow  exudative  nephritis,  nor  is  it  merely 
a  modification  of  it ;  from  the  very  outset  it  is  a  different  form  of  in- 
flammation. In  the  kidneys  of  persons  who  have  been  sick  only  a 
few^  days,  the  characteristic  lesions  are  already  evident.  Productive 
nephritis  is  governed  by  the  same  law  as  that  which  belongs  to  pro- 
ductive inflammation  in  other  pai*ts  of  the  body — the  disposition  of 


ACUTE   PRODUCTIVE   NEPHRITIS. 


63 


tlie  inflammation  to  continue  as  a  subacute  and  clironic  condition. 
It  is  of  importance  to  recognize  that  in  exudative  nephritis  the  lesions 
are  temporary,  and  after  their  subsidence  the  kidneys  return  to  their 
normal  condition,  just  as  the  lungs  do  after  a  lobar  pneumonia.  In 
productive  nephritis,  on  the  other  hand,  some  of  the  lesions  are  per- 
manent, the  kidneys  can  never  return  to  their  normal  condition,  just 
as  in  an  interstitial  pneumonia  the  lung  never  gets  rid  of  the  new 
connective  tissue. 

Post-scarlatinal  nephritis  is  nearly  always  of  the  productive  form. 
Nephritis  comjilicating  diphtheria  or  developed  during  pregnancy  is 


Fig.  6.— Vertical  Section  of  the  Cortex.    Acute  Productive  Nephritis. 

very  frequently  of  this  type.  A  primary  nephritis  in  a  person  over 
twelve  years  old,  if  of  subacute  form,  is  almost  invariably  a  produc- 
tive nephritis.  On  the  other  hand,  this  form  of  nephritis  very 
seldom  complicates  any  of  the  infectious  diseases  except  scarlatina 
and  diphtheria. 

These  facts  assist  very  much  in  making  the  diagnosis  between  the 
two  forms  of  acute  nephritis.  It  is  easy  to  remember  that  post-scar- 
latinal nephritis  and  primary  nephritis  of  subacute  type  are  nearly 
always  of  the  i>i'«t^uctive  form ;  and  that  nephritis  with  diphtheria 
and  pregnancy  is  often  of  the  productive  form ;  while  acute  nephritis 
under  all  other  conditions  is  regularly  of  the  exudative  form. 


64 


DELAFTFJiP — DISEASES   OF  THE   KIDNEYS. 


MOBBID   AnATOIMY. 

Tlie  kidneys  are  increased  in  size,  tlie  capsules  are  not  adherent, 
tlie  surfaces  are  smooth.  The  cortical  portion  is  red,  or  white,  or 
mottled.  The  mucous  membrane  of  the  pelvis  is  sometimes  con- 
gested. Of  the  tubules  in  the  cortex,  in  some  the  epithelium  is  flat- 
tened, in  some  there  is  coagulated  matter  or  casts,  in  some  the  epi- 
thelium is  swollen,  degenerated,  or  contains  globules  of  fat.  In  those 
l^arts  of  the  cortex  where  there  is  a  growth  of  new  connective  tissue, 
the  tubes  may  be  atrophied.  The  tubules  of  the  pyramids  show  but 
little  change  except  that  they  may  contain  casts.  In  the  stroma  of 
the  cortex  there  is  a  growth  of  new  connective  tissue,  varying  in  dif- 
ferent kidneys  as  to  the  relative  proportion  of  cells  and  basement 


Fig.  7.— a  Glomerulus  with  Growth  of  Capsule  Cells.    Subacute  Productive  Nephritis. 

substance.  This  new  tissue  in  many  of  the  kidneys  follows  the  line 
of  the  arteries  which  run  up  into  the  cortex,  so  that  it  takes  the  form 
of  wedges.  But  in  other  kidneys  the  new  tissue  is  diffuse,  or  in  ir- 
regular patches. 

Many  of  the  glomeruli  show  only  an  increase  in  the  size  and  num- 


ACUTE  PRODUCTIVE  NEPHRITIS. 


65 


ber  of  the  cells  which  cover  the  capillaries,  with  some  swelling  of  the 
capsule  cells.  But  in  others  there  is  an  extensive  new-growth  of  cap- 
sule cells  which  comjjresses  the  tuft  of  vessels.  This  growth  of  new 
cells  from  the  capsule  cells  must  not  be  confounded  with  accumula- 


FiG.  8.— Cortex  Tubes.    Subacute  Productive  Nephritis. 

tions  of  white  blood-cells  within  the  capsules,  nor  with  the  growth  of 
new  cells  on  the  walls  of  the  capillaries.  The  glomeruli  which  are 
changed  in  this  way  are  in  groups,  each  group  corresponding  to  some 
one  artery. 

The  whole  picture  of  the  nephritis  is  that  of  a  combination  of  exu- 
dative and  productive  inflammation. 

When  such  a  nephritis  becomes  chronic  it  is  often  possible  to  fol- 
low its  course  for  many  years,  and  to  see  at  the  end  of  that  time  that 
the  anatomical  changes  in  the  kidney  are  of  the  same  kind,  but  much 
more  extensive. 

Symptoms. 

Of  the  patients  who  suffer  from  this  form  of  nephritis,  a  certain 
number    behave    as    if    they   had   a    simple    exudative    nephritis. 
Vol.  I.— 5 


66  DELAPIELD — DISEASES  OF  THE  KIDNEYS. 

There  is  a  rise  of  temperature,  with  more  or  less  prostration.  Cere- 
bral symptoms  are  marked — headache,  stupor,  sleeplessness,  rest- 
lessness, muscular  twitchings,  and  general  convulsions.  The  arteries 
are  contracted,  the  pulse  is  of  high  tension,  the  heart's  action  is  exag- 
gerated, the  left  ventricle  may  be  hypertrophied,  there  is  dyspnoea. 
The  appetite  is  lost,  there  may  be  nausea  and  vomiting.  The  urine 
is  scanty  or  suppressed,  it  is  colored  by  blood  and  contains  much  al- 
bumin and  many  casts.  The  patients  are  very  sick  and  much  more 
likely  to  die  than  they  are  with  an  exudative  nephritis. 

Such  a  nephritis  may,  however,  apparently  run  its  course.  At 
the  end  of  four  weeks  the  symptoms  subside  and  the  patients  get 
better.  They  maj^  then  remain  in  ordinary  health  without  renal  symp- 
toms for  weeks,  months,  or  years.  But  sooner  or  later  they  have 
another  acute  attack,  or  they  gradually  develop  the  symptoms  of  a 
chronic  nephritis. 

The  more  ordinary  cases  have  a  gradual  invasion,  and  run  a  sub- 
acute rather  than  an  acute  course. 

In  some  of  the  patients  at  first  there  are  only  loss  of  appetite, 
headaches,  and  an  increasing  pallor  of  the  skin  and  mucous  mem- 
branes ;  the  dropsy  does  not  come  on  until  after  many  days. 

In  some  of  the  patients  dropsy  of  the  legs  is  the  first  and,  for  a 
time,  the  only  symptoms.  They  continue  to  eat  well,  feel  well,  and 
attend  to  their  work. 

In  most  of  the  patients  dropsy  of  the  legs  and  face,  anaemia,  head- 
ache, sleeplessness,  loss  of  appetite,  nausea  and  vomiting  are  devel- 
oped at  about  the  same  time. 

The  urine  is  only  moderately  diminished  iii  quantity ;  it  often  con- 
tains no  blood,  there  is  a  large  quantity  of  albumin  and  a  considera- 
ble number  of  casts.  The  specific  gravity  remains  normal,  or  falls  a 
little. 

The  cases  vary  a  good  deal  as  to  their  severity. 
Some  of  the  patients  are  not  at  any  time  very  sick.  A  moderate 
subcutaneous  oedema,  anaemia,  headache,  and  disturbances  of  diges- 
tion last  for  a  few  weeks,  then  disappear,  and  the  patients  seem  to  be 
well.  Some  of  them  do  get  well,  but  the  majority  either  have  other 
attacks  of  the  same  character,  or  develop  the  symptoms  of  chronic 
nephritis.  It  is  surprising  for  how  many  years  some  of  these  patients 
go  on  in  apparent  good  health,  although  the  kidneys  are  really  be- 
coming more  and  more  diseased. 

In  some  patients  the  dropsy  is  much  more  extensive  and  involves 
the  serous  cavities  as  well  as  the  subcutaneous  tissue.  For  a  num- 
ber of  weeks  these  patients  are  in  bed  and  very  badly  off.  And  yet 
even  the  bad  attacks  may  subside  altogether,  the  patients  are  appar- 


ACUTE   PRODUCTIVE  NEPHRITIS.  67 

ently  well,  are  able  to  go  back  to  their  work,  and  have  no  more  trou- 
ble for  years. 

In  some  patients  there  is  first  a  well-marked  attack  of  dropsy, 
anaemia,  headache,  sleeplessness,  loss  of  appetite,  nausea  and  vomit- 
ing, which  lasts  for  a  few  weeks.  Then  the  symptoms  subside  and  the 
patients  are  pretty  well,  but  not  very  well.  After  this  they  have  at- 
tacks of  the  same  kind  at  intervals  of  weeks  or  months,  and  this  may 
go  on  for  years.  In  hospital  patients  the  attacks  regularly  come  on 
every  winter  and  the  patients  are  comparatively  well  in  the  summer. 
Each  attack,  however,  is  worse  than  the  preceding,  and  finally  there 
comes  an  attack  which  proves  fatal.  In  these  long  cases  the  specific 
gravity  of  the  urine  becomes  lower  from  year  to  year. 

The  severe  and  progressive  cases  are  most  distressing  to  witness. 
The  patients  are  constantly  getting  worse,  and  yet  months  may  elajjse 
before  their  sufferings  are  terminated  by  death.  The  color  of  the 
skin  and  of  the  mucous  membranes  becomes  more  and  more  white ; 
headaches  are  constant  and  troublesome ;  sleep  is  difficult  and  unre- 
freshing ;  the  eyesight  is  impaired  or  lost  altogether ;  there  is  no  ap- 
petite but  rather  constant  nausea  and  irritability  of  the  stomach; 
from  time  to  time  the  arteries  are  contracted  and  there  is  a  disposi- 
tion to  muscular  twitchings  and  general  convulsions.  The  dropsy 
constantly  increases  no  matter  how  large  the  excretion  of  urine.  The 
subcutaneous  connective  tissue  is  everywhere  oedematous  and  the 
serous  cavities  are  filled  with  serum.  It  seems  as  if  the  blood 
serum  was  unable  to  remain  in  the  vessels,  it  escapes  everywhere. 

Prognosis. 

The  majority  of  cases  of  acute  productive  nephritis-  terminate  un- 
favorably. Either  the  disease  goes  on  continuously  and  the  patients 
die  at  the  end  of  a  few  days  or  a  few  months ;  or  the  acute  symptoms 
subside  and  a  chronic  nephritis  supervenes.  It  is  not  wise,  however, 
to  give  too  unfavorable  a  prognosis  even  in  severe  cases ;  great  im- 
provement and  even  complete  recovery  are  possible.  I  see  from  time 
to  time  persons  in  apparently  good  health  and  able  to  earn  their  liv- 
ing, concerning  whom  I  have  given  a  very  unfavorable  prognosis 
many  years  ago. 

Treatment. 

In  those  cases  in  which  the  disease  behaves  like  an  acute  exuda- 
tive nephritis  the  indications  for  treatment  are  the  same  as  in  the 
latter  disease,  although  the  results  are  not  so  satisfactory. 

The  subacute  cases  have  to  be  managed  differently.     At  first  it  is 


68  DELAPIELD — DISEASES  OF  THE  KIDNEYS. 

wise  to  keep  tlie  patients  in  bed  and  on  an  exclusively  milk  diet.  In 
some  of  the  patients  the  daily  use  of  the  hot  pack  seems  to  be  of  ser- 
vice, in  some  nothing  is  gained  by  its  use,  in  some  it  is  I  think  harm- 
ful. I  do  not  know  how  to  distinguish  the  appropriate  cases  for  the 
hot  pack  except  by  trying  its  use  for  a  few  days. 

Digitalis,  preferably  in  the  form  of  digitalin  in  doses  of  yto  of  ^ 
gi-ain,  seems  in  some  of  the  cases  to  exert  a  favorable  effect  on  the 
nephritis — at  all  events  the  quantity  of  albumin  in  the  urine  dimin- 
ishes and  the  patients  improve;  but  in  some  other  cases  it  does 
nothing.  In  the  same  way  morphine  in  small  doses,  sometimes  not 
more  than  5V  of  a  grain,  relieves  the  headache,  sleeplessness,  and  nau- 
sea, and  the  patients  are  evidently  better  for  it.  But  there  are  other 
patients  to  whom  the  morphine  is  of  no  ser\dce  whatever. 

The  dropsy  is  always  of  consequence.  It  is  associated  with  a  soft 
pulse ;  a  fair  heart  action,  rather  feeble  than  forcible ;  no  great  dispo- 
sition to  venous  congestion.  The  composition  of  the  blood  is  pro- 
foundly changed  by  the  diminution  in  the  quantity  of  haemoglobin 
and  the  number  of  red  blood-cells,  and  probably  in  other  ways  which 
we  do  not  appreciate.  The  quantity  of  urine  may  be  either  dimin- 
ished or  increased.  The  dropsy,  therefore,  does  not  seem  to  depend 
on  changes  in  the  blood  pressure  or  in  the  quantity  of  urine,  but 
rather  on  changes  in  the  composition  of  the  blood  or  in  the  walls  of 
the  arteries.  It  is  a  dropsy  which  it  is  very  difficult  to  treat  intel- 
ligently. 

There  are  cases  in  which  the  dropsy  will  disappear  simply  with 
the  rest  in  bed  and  the  milk  diet. 

There  are  cases  in  which  jjrofuse  sweating  by  the  hot-air  bath  or 
the  hot  pack  diminishes  t^je  dropsy.  But  some  of  these  patients 
cannot  be  made  to  sweat,  some  of  them  are  too  much  depressed  by 
the  heat,  in  some  the  sweating  does  not  diminish  the  dropsy. 

Hydragogue  cathartics,  such  as  jalap  and  elaterium,  will  often 
diminish  the  dropsy  for  a  time.  Their  use,  however,  cannot  be  con- 
tinued for  any  length  of  time  without  irritating  the  stomach  and  in- 
testines. 

The  daily  use  of  good  massage  with  compression  of  the  legs  by 
bandages  is  sometimes  of  real  value. 

Digitalis,  caffeine,  and  strophanthus  in  many  cases  act  efficiently, 
even  when  they  do  not  increase  the  quantity  of  urine.  They  are  the 
most  useful  drugs  for  this  particular  purpose. 

The  use  of  diuretics  is  limited  to  the  cases  in  which  the  quantity 
of  urine  is  diminished.  In  a  patient  with  increasing  dropsy,  who  i» 
already  passing  90  or  100  ounces  of  urine  a  day,  diuretics  are  not  in- 
dicated.    The  drugs  ordinarily  employed  to  effect  diuresis  are  those 


CHKONIC   PRODUCTIVE   NEPHRITIS  WITH  EXUDATION.  69 

which,  act  on  the  circulation — digitalis,  caffeine,  strophanthus,  and 
convallaria ;  and  those  which  are  supposed  to  act  on  the  kidneys — ■ 
acetate  of  potash,  lactate  of  strontium,  squills,  diuretin.  Good  re- 
sults are  reported  from  the  use  of  those  drugs.  But  experience  shows 
that  in  some  patients  the  quantity  of  urine  cannot  be  increased,  and 
in  others  the  increase  in  the  quantity  of  urine  is  not  followed  by 
diminution  of  the  dropsy. 

It  would  seem  as  if  the  disposition  to  dropsy  could  be  controlled  if 
we  could  control  the  composition  of  the  blood,  increase  the  number 
of  the  blood-cells,  and  raise  the  specific  gravity  of  the  blood  serum. 
Unfortunately  we  do  not  know  how  to  do  this. 

When  necessary,  to  make  the  patient  more  comfortable,  we  have  to 
tap  the  peritoneal  and  pleural  cavities  and  to  puncture  the  skin  of  the 
legs. 

If  the  patients  improve,  the  milk  diet  is  to  be  gradually  replaced 
by  solid  food,  iron  is  to  be  given  in  fair  doses,  and  the  patient  gets 
out  of  bed  and  out  of  the  house.  At  this  time  climate  becomes  a 
matter  of  much  importance.  The  patient  should  be  sent  to  a  warm, 
dry,  equable  climate  where  he  can  lead  an  out-of-door  life. 

Chronic  Productive  (or  Diffuse)  Nephritis  -with  Exudation. 

Definition. 

A  chronic  inflammation  of  the  kidney  attended  with  a  growth  of 
new  connective  tissue  in  the  stroma,  permanent  changes  in  the  glom- 
eruli, degeneration  of  the  renal  epithelium,  exudation  from  the  blood- 
vessels, and  sometimes  changes  in  the  walls  of  the  arteries. 

Synonyms. — Chronic  Bright's  disease;  Chronic  parenchymatous 
nephritis ;  Chronic  glomerulo-nephritis ;  Waxy  kidney ;  Large  white 
kidney ;  Chronic  diffuse  nephritis ;  Chronic  desquamative  nephritis. 

It  has  been  customary  to  hold  that  in  all  these  kidneys  the  pri- 
mary and  most  important  changes  are  in  the  renal  epithelium,  while 
in  another  set  of  kidneys  the  primary  and  important  changes  are  in 
the  stroma.  In  other  words,  that  the  cases  of  chronic  nephritis  can 
be  divided  into  two  classes — parenchymatous  nephritis  and  intersti- 
tial nephritis. 

I  do  not  think  that  this  classification  is  supported  by  facts. 

In  all  the  forms  of  chronic  nephritis  changes  are  to  be  found  in 
the  renal  epithelium,  the  glomeruli,  and  the  stroma.  Whether  the 
changes  in  the  stroma,  the  glomeruli,  or  the  epithelium  are  the  more 
marked  makes  no  difference  in  the  clinical  symptoms.  But  the  pres- 
ence or  absence  of  exudation  from  the  renal  blood-vessels  does  corre- 


70  DELAPIELD— DISEASES   OF  THE   KIDNEYS. 

spond  to  a  marked  difference  in  the  symptoms.  The  existence  of  the 
exudation  from  the  renal  vessels  is  easily  shown  by  the  presence  of 
serum  albumin  in  the  urine.  In  this  way  we  readily  distinguish  two 
forms  of  chronic  nephritis,  one  with  exudation  and  one  without. 

The  way  of  looking  at  the  matter,  then,  is  this : 

We  find  after  death  from  chronic  nephritis  a  great  many  varieties 
in  the  gross  appearance  of  the  kidneys.  Some  are  large,  some  are 
small,  some  are  red,  some  are  white,  etc.  There  is  no  regular  corre- 
spondence between  these  different  gross  appearances  of  the  kidneys 
and  the  clinical  symptoms. 

We  find  in  these  same  kidneys  change  in  the  renal  epithelium, 
in  the  stroma,  in  the  glomeruli,  and  in  the  arteries.  Sometimes  one, 
sometimes  the  other  of  these  elements  of  the  kidneys  is  the  most 
changed.  There  is  no  regular  correspondence  between  the  predom- 
inance of  the  changes  in  one  of  the  kidney  elements  over  the  other 
and  the  clinical  symptoms. 

The  easiest  working  scheme  is  to  admit  that  in  chronic  nephritis 
all  the  elements  of  the  kidney  are  more  or  less  changed,  but  that  the 
cases  vary  as  to  whether  there  is  or  is  not  an  exudation  of  serum  from 
the  blood-vessels.  The  presence  or  absence  of  such  an  exudation  does 
correspond  to  a  well-marked  difference  in  the  clinical  symptoms. 

In  the  present  state  of  our  knowledge  and  for  clinical  purposes  we 
divide  all  the  cases  of  nephritis  into  two  classes,  chronic  nephritis 
with  exudation  and  chronic  nei^hritis  without  exudation. 

It  is  admitted  that  it  is  easy  to  divide  up  these  kidneys  according 
to  their  anatomical  changes  into  a  number  of  fairly  well-marked 
classes.  But  as  this  division  does  not  correspond  to  clinical  divisions 
it  is  valueless  for  clinical  purposes. 

Although  it  is  convenient  to  describe  two  forms  of  chronic  ne- 
phritis— one  with  much  albuminuria  and  drojjsy,  and  one  with  little 
or  no  albuminuria,  or  dropsy — yet  it  must  be  remembered  that  these 
are  not  separate  lesions  of  the  kidneys,  but  varieties  of  the  same 
lesion.  For  in  all  these  kidneys  two  changes  are  constant — produc- 
tive inflammation  of  the  glomeruli  and  stroma,  and  degeneration  of 
the  renal  epithelium.  The  only  real  difference  between  the  kidneys 
is  whether,  besides  the  growth  of  new  tissue  and  degeneration  of 
renal  epithelium,  there  is  or  is  not  an  exudation  of  serum  from  the 
blood-vessels  of  the  kidneys. 

In  speaking  of  the  exudation  of  serum  from  the  vessels  and  its 
presence  in  the  urine,  we  speak  of  it  as  it  occurs  during  the  whole 
course  of  the  disease,  and  not  as  it  occurs  for  short  periods.  We 
mean  that  in  an  exudative  chronic  nephritis  there  is  usually  a  large 
quantity  of  albumin  in  the  urine,  but  that  there  may  be  periods  dur- 


CHRONIC   PRODUCTIVE   NEPHRITIS  WITH  EXUDATION. 


71 


ing  whicli  the  albumin  diminislies  or  entirely  disappears.  In  the 
same  way  in  a  non-exudative  nephritis  there  may  be  periods  during 
which  albumin  is  present  in  considerable  quantities.  Generally 
speaking,  the  character  of  the  clinical  symptoms  will  vary  with  the 
presence  or  absence  of  the  albumin. 

Etiology. 

A  considerable  number  of  cases  of  chronic  nephritis  follow  an  at- 
tack of  acute  or  subacute  productive  nephritis.     The  conditions  of 


Fig.  9. — Vertical  Section  of  the  Cortex.    Chronic  Nephritis  with  Exudation. 


chronic  congestion  and  chronic  degeneration  of  the  kidney  are  not 
infrequently  followed  by  a  true  nephritis. 

Syphilis,  chronic  tubercular  inflammation  of  any  part  of  the  body, 
chronic  endocarditis,  and  chronic  suppurative  inflammations  are  often 
complicated  with  chronic  nephritis. 

It  is  very  difficult  to  find  a  satisfactory  cause  for  the  primary 
cases.  There  are  many  of  these,  especially  in  young  and  middle 
aged  adults.  The  nei>hritis  is  developed  in  a  slow,  insidious  way  in 
jjersons  whose  previous  health  has  been  good  and  in  whom  no  excit- 
ing cause  is  discoverable. 


72 


DELATIELD — DISEASES  OF  THE   KIDNEYS. 


Morbid  Anatomy. 

Gh^oss  Appearance  of  the  Kidney. — There  is  considerable  variety 
in  tlie  gross  appearance  of  the  kidneys.  The  types  which  I  have 
seen  most  frequently  are  as  follows : 

1.  Large  white  kidneys,  weighing  together  sixteen  ounces  or  more, 
the  capsule  adherent  or  not,  the  surface  smooth  or  nodular,  the  cor- 
tex thick  and  white,  the  pyramids  large  and  red. 

2.  Large  mottled  kidneys.     These  resemble  the  large  white  kid- 


FiG.  10.— Vertical  Section  of  the  Cortex.    Chronic  Nephritis  with  Exudation. 

neys  in  every  respect  except  that  the  cortex,  instead  of  being  white, 
is  mottled  in  a  variety  of  ways  with  white,  yellow,  red,  and  gray. 

3.  Kidneys  which  resemble  types  one  and  two,  but  are  not  en- 
larged, the  kidneys  together  not  weighing  over  nine  ounces. 

The  majority  of  the  kidneys   in  chronic  nephritis  follow  these 
three  types. 

4.  Small  kidneys,  weighing  together  not  more  than  five  ounces,  the 
capsules  adherent  or  not,  the  surfaces  nodular,  the  cortex  thin,  atro- 


CHRONIC   PEODUCTIVE   NEPHRITIS   WLTB.  EXUDATION.  73 

phied,  wliite,  tlie  pyramids  rather  large  and  red.  These  kidneys  be- 
long to  persons  who  have  had  symj^toms  of  kidney  disease  for  many 
years,  with  periods  of  apparent  recovery. 

5.  Kidneys  which  have  the  ordinary  appearance  and  consistence 
of  the  chronic  congestion  due  to  heart  disease,  but  in  addition  the 
capsules  are  adherent  and  the  surfaces  finely  nodular. 

6.  Kidneys  of  different  sizes — large,  medium-sized,  and  small, with 
adherent  capsules  and  nodular  surfaces.    The  cortex  is  gray,  or  gray 


Fig.  11.— Vertical  Section  of  the  Cortex.    Chronic  Nephritis  with  Exudation. 

mottled  with  red.    The  kidneys  do  not  look  at  all  like  the  large  white 
kidneys.     This  is  a  type  of  frequent  occurrence. 

7.  Kidneys  which  in  their  size,  color,  and  general  appearance  are 
hardly  to  be  distinguished  from  normal  kidneys,  excejjt  that  their 
cax)sules  are  adherent. 

8.  Kidneys  of  small  size,  weighing  together  not  more  than  four 
ounces,  with  adherent  capsules.  The  cortex  is  atrophied,  red,  and 
irregular.  These  kidneys  are  found  in  persons  who  have  given  symp- 
toms of  renal  disease  for  a  number  of  years. 

It  might  naturally  be  supposed  that  such  marked  differences  in 
the  gross  ax>pearance  of  the  kidneys  would  correspond  to  equally 


74  DELAPIELD— DISEASES   OF  THE   KIDNEYS. 

marked  differences  in  tlie  clinical  histories  and  minute  lesions. 
This,  however,  is  not  the  case.  The  clinical  histories  are  practically 
interchangeable,  and  the  minute  lesions  are  essentially  the  same. 

Microscopical  Appearances. — If  we  make  vertical  sections  of  the 
cortex  of  all  these  kidneys,  no  matter  what  their  size  or  color,  we  get 
with  a  low  magnifying  power  the  same  general  picture.  Instead  of 
the  uniform  and  orderly  arrangement  of  tubes  and  glomeruli  which 
we  see  in  the  normal  kidnev,  the  tubes  seem  to  be  obliterated  in  some 


Fig.  13.— Cortex  Tubes.    (Jhrouio  Isepliiitis  with  Exudation. 

places  and  dilated  in  others.  There  is  a  growth  of  fibro-ceUular  tissue 
in  regular  wedges,  in  irregular  patches,  or  diffuse  between  the  tubules. 

If  we  examine  the  different  constituents  of  the  kidney  in  detail  we 
find: 

The  tubes  are  in  some  places  of  normal  size,  in  some  places  atro- 
phied, in  some  places  dilated.  The  atrophied  tubes  are  in  the 
patches  of  new  connective  tissue.  The  dilated  tubes  are  not  very 
large,  nor  do  they  form  cysts. 

The  epithelium  of  the  tubes  is  in  some  places  merely  flattened. 


CHRONIC  PRODUCTIVE  NEPHRITIS  WITH  EXUDATION. 


75 


These  tubes  are  empty,  or  contain  coagulated  matter,  casts,  and  red 
and  white  blood-cells.  In  other  tubes  the  epithelium  is  more  or  less 
swollen,  sometimes  so  much  so  as  to  completely  fill  the  tubes.  In 
still  other  tubes  the  epithelial  cells  are  swollen,  their  reticulum  is 
very  coarse  with  large  meshes,  and  they  are  infiltrated  with  fat.  The 
kidneys  vary  as  to  which  of  these  changes  in  the  epithelium  pre- 
dominates, but  all  of  them  may  be  found  in  the  same  kidney. 

The  new  connective  tissue  is  in  the  form  of  wedge-shaped  masses 


Fig.  13.— Cortex  Tubes.    Chronic  Nephritis  with  Exudation. 


in  the  cortex  which  follow  the  line  of  the  straight  arteries  and  veins, 
or  it  is  in  irregular  masses,  or  it  is  arranged  diffusely  so  as  to  sepa- 
rate the  tubes  from  each  other.  The  longer  the  nephritis  lasts,  the 
greater  is  the  ciuantity  of  new  connective  tissue.  The  relative  pro- 
I)ortion  of  basement  substance  and  cells  and  the  density  of  the  base- 
ment substance  vary  in  the  different  kidneys.  The  new  tissue  is  well 
sux)plied  with  blood-vessels. 

TIte  (/hrneruli  are  changed  in  several  different  ways : 

1.  They  resemble  tlie   glomeruli  in  acute  exudative   nei)hritis. 


76  DELAPIELD — DISEASES  OF  THE   KIDNEYS. 

They  are  large,  the  convolutions  of  the  capillaries  are  seen  with  diffi- 
culty, there  is  a  very  great  increase  in  the  number  of  the  cells  which 
cover  the  capillaries,  but  these  new  cells  are  not  of  large  size.  We 
also  see  glomeruli,  which  apparently  have  been  of  this  type,  small 
and  atrophied. 

2.  There  is  an  increase  not  only  in  the  number,  but  also  in  the 
size,  of  the  cells  which  cover  the  capillaries.    These  cells  are  so  large 


Fig.  14. — Cortex  Tubes.    Chronic  Nephritis  with  Exudation. 

that  they  project  outward  from  the  surface  of  the  glomerulus.  There 
is  also  an  increase  in  the  size  and  number  of  the  cells  within  the  cap- 
illaries.    These  glomeruli  are  found  in'all  stages  of  atrophy. 

3.  The  capillaries  are  changed  in  the  same  way  by  a  growth  of 
large  cells  on  their  outer  surfaces  and  within  them.  In  addition 
there  is  a  very  extensive  cell-growth  beginning  in  the  cells  which  line 
the  capsule.  The  mass  of  new  cells  produced  in  this  way  may  be  so 
great  as  to  compress  the  capillaries.  The  glomeruli  also  become 
atrophied,  the  capillaries  are  shrunken,  and  the  capsule  cells  changed 
into  connective  tissue. 


CHRONIC   PRODUCTIVE   NEPHRITIS  WITH   EXUDATION.  77 

4.  If  chronic  congestion  of  tlie  kidneys  is  followed  by  chronic  ne- 
phritis, the  dilatation  of  the  capillaries  due  to  the  congestion  con- 
tinues, and  there  is  added  an  increase  in  the  size  and  number  of  the 
cells  which  cover  the  capillaries. 

5.  The  walls  of  the  capillaries  are  the  seat  of  waxy  degeneration, 
while  the  cells  which  cover  them  are  increased  in  size  and  number. 

6.  Besides  the  atrophied  glomeruli  already  described,  there  are 


Fig.  15. — A  Glomerulus  with  the  Growth  of  Tuft  Cells.    Chronic  Nephritis  with  Exudation. 

others  which  are  small  and  shrunken  with  comparatively  little  new 
growth  of  cells. 

The  arteries  are  not  infrequently  much  altered  by  inflammatory 
changes.  There  is  a  growth  of  cells  and  basement  substances  from 
the  inner  surface  of  the  artery  which  obstructs  its  lumen ;  or  there  is 
a  thickening  of  each  of  the  three  coats  of  the  artery ;  or  all  the  coats 
of  the  artery  are  thickened  and  converted  into  a  uniform  mass  of 
dense  connective  tissue;  or  the  wall  of  the  artery  undergoes  waxy 
degeneration. 


78 


DELAPIELD —DISEASES   OF  THE  KIDNEYS. 


Symptoms. 

The  urine  varies  in  quantity  at  different  times  in  the  course  of  the 
disease.  In  the  earlier  periods  the  urine  is  often  scanty  or  even  sup- 
pressed. If  the  disease  goes  on  rapidly  the  quantity  of  urine  may 
continue  small ;  if  it  goes  on  slowly  the  quantity  is  often  increased. 
In  some  of  the  worst  cases,  with  general  dropsy,  the  patients  will 
pass  more  than  100  ounces  of  urine  a  day. 

The  specific  gravity  and  the  proportion  of  urea  to  the  ounce  of 


Fig.  16.— a  Glomerulus  with  the  Growth  of  Tuft  Cells.    Chronic  Nephritis  with  Exudation. 

urine  slowly  diminish  as  the  disease  progresses.  This  is  the  rule,  but 
there  are  exceptions  to  it.  In  cases  which  improve,  the  quantity  of 
urea,  after  being  much  diminished,  may  increase  until  the  i)atient 
excretes  the  full  normal  quantity  for  the  twenty -four  hours. 

In  the  cases  of  shorter  duration  the  specific  gravity  is  apt  to  run 
between  1.012  and  1.020.  In  the  very  chronic  cases  it  will  be  be- 
tween 1.001  and  1.005.  A  very  low  specific  gravity  indicates  a  large 
growth  of  connective  tissue  in  the  stroma  of  the  cortex,  or  waxy  de- 


CHKONIC   PEODUCTIVE   NEPHRITIS   WITH  EXUDATION. 


79 


generation  of  the  capillaries  of  the  glomeruli  and  of  the  arteries  of  the 
kidney.  Many  persons  who  think  that  they  have  kidney  disease  get 
into  the  habit  of  drinking  large  quantities  of  mineral  waters.  This, 
of  course,  gives  them  urine  of  low  specific  gravity.  In  all  doubtful 
cases  it  is  necessary  to  determine  the  quantity  of  the  whole  excretion 
of  urea  for  the  twenty-four  hours.  There  are  patients  in  whom  the 
quantity  of  urea  is  the  principal  factor  in  enabling  one  to  decide 
between  albuminuria  without  nephritis  and  chronic  nephritis  with 
exudation. 

The   urine   regularly  contains  albumin  and  casts.       During  the 


Fig.  17.— a.  Glomerulus  with  the  Growth  of  Capsule  Cells.    Chronic  Nephritis  with  Exudation. 


active  periods  of  the  disease  the  quantity  of  albumin  is  very  large ;  in 
the  slow,  prolonged  cases  the  quantity  is  much  smaller  and  at  times 
it  may  disappear  altogether.  Generally  speaking,  with  large  quanti- 
ties of  albumin  the  x>atients  are  dropsical  and  anaamic ;  with  small 
quantities  of  albumin  they  are  anaemic  but  not  dropsical.  There 
seems  to  be  a  common  cause  for  the  exudation  of  serum  from  the 
blood-vessels  throughout  the  entire  l)ody,  the  serum  infiltrating  the 


80 


DEIAFIELD — DISEASES   OF  THE   KIDNEYS. 


tissues,  accumulating  in  tlie  serous  cavities,  and  mixing  witli  tlie 
urine. 

The  number  of  casts  is  regularly  in  proportion  to  the  quantity  of 
albumin,  but  there  are  exceptions  to  this  rule. 

A  peculiar  pallor  of  the  skin  and  white  color  of  the  sclerotic  is 
seldom  absent.  This  gives  to  the  patient  a  face  very  characteristic  of 
chronic  nephritis.  In  making  a  diagnosis  in  doubtful  cases  a  good 
deal  of  importance  is  to  be  attached  to  the  presence  or  absence  of  this 


Fig.  18.— a  Waxy  Glomerulus.    Chronic  Nephritis  with  Exudation. 


appearance  of  the  face.  The  change  in  the  color  corresponds  to  a 
diminution  in  the  quantity  of  haemoglobin  and  in  the  number  of  red 
blood-cells.  These  changes  in  the  blood  are  often  not  far  advanced, 
but  sometimes  they  are,  and  some  patients  even  die  with  the  symp- 
toms of  pernicious  anaemia. 

Dropsy  may  be  considered  almost  a  constant  symptom  of  chronic 
exudative  nephritis.  There  is  an  infiltration  of  the  subcutaneous 
connective  tissue  with  serum  and  an  accumulation  of  serum  in  the 
serous  cavities.     The  position  of  the  fluid  varies  with  that  of  the  pa- 


CHKONIC   PEODUCTIVE   NEPHRITIS  WITH  EXUDATION.  81 

tient,  accumulating  in  the  dependent  portion  of  the  body.  There  is 
much  variety  as  to  the  extent  of  the  dropsy.  In  some  XJatients  there 
is  never  anything  more  than  a  moderate  oedema  of  the  legs,  while  in 
others  a  marked  general  dropsy  is  the  most  prominent  symptom  of 
the  disease.  There  is  also  a  variety  as  to  the  time  of  appearance  and 
the  duration  of  the  dropsy.  It  may  be  one  of  the  first  symptoms  of 
the  nephritis,  or  it  may  not  occur  until  late  in  the  disease.  When  it 
is  once  established  it  may  never  leave  the  patient,  or  it  may  appear 
and  disappear  at  irregular  intervals. 

Many  of  the  patients  are  troubled  with  headache  and  sleeplessness. 
In  some  of  them  these  symptoms  exist  only  when  the  pulse  is  of  high 
tension  and  disappear  when  the  pulse  becomes  soft.  In  others,  how- 
ever, the  headache  and  sleeplessness  persist  with  a  soft  pulse.  It 
must  not  be  forgotten  that  these  symptoms  may  also  depend  on  di- 
gestive disturbances  and  not  on  the  disease  of  the  kidneys. 

Acute  urcemic  attacks  with  contraction  of  the  arteries,  dyspnoea, 
vomiting,  convulsions,  etc. ,  may  occur  at  any  time  in  the  course  of  a 
chronic  exudative  nephritis.  But  they  are  of  very  much  more  fre- 
quent occurrence  with  the  non-exudative  form  of  the  disease. 

Chronic  urcemia,  on  the  contrary,  is  one  of  the  ordinary  ways  in 
which  an  exudative  nephritis  proves  fatal.  The  condition  belongs  to 
the  later  stages  of  the  disease.  It  is  developed  rather  gradually,  but 
when  once  established  is  permanent,  not  disappearing  up  to  the  time 
of  the  patient's  death.  The  patients  are  in  a  condition  of  alternating 
delirium  and  stupor,  with  a  rapid,  feeble,  soft  pulse. 

Simple  neuro-retinitis,  or  nephritic  retinitis,  may  be  developed  at 
any  time  in  the  disease.  Both  eyes  are  regularly  involved.  The 
impairment  of  vision  may  be  very  slight,  or  considerable,  or  the  pa- 
tients may  become  entirely  blind.  With  such  a  neuro-retinitis  the 
prognosis  of  the  nephritis  is  especially  bad. 

Dyspnoea  is  a  nearly  constant  symptom,  but  it  is  not  always  the 
same  kind  of  dypsnoea,  nor  produced  by  the  same  causes.  It  may 
be  due  to  hydrothorax,  to  oedema  of  the  lungs,  to  contraction  of  the 
arteries,  or  to  failure  of  the  heart's  action. 

The  dyspnoea  due  to  contraction  of  the  arteries  is  common  to  both 
forms  of  chronic  nephritis.  It  may  be  developed  at  any  time  during 
the  course  of  the  disease.  It  comes  on  in  attacks,  especially  at  night 
and  in  the  early  morning,  and  is  worse  when  the  patients  lie  down. 
It  often  begins  while  the  patient  is  api)arently  in  good  health,  but  is 
a  sure  premonition  of  serious  disease. 

In  some  cases  these  attacks  of  dyspnoea  can  be  controlled  and  the 
patient  kej^t  apparently  well  for  months  and  even  years.  But  as  the 
attacks  are  repeated,  they  are  more  severe  and  more  stubborn.  The 
Vol.  I.— 6 


82  DELAPIELD — DISEASES   OF   THE   KIDNEYS. 

heart's  action  fails  in  addition  to  the  contraction  of  the  arteries,  and 
the  dyspnoea  becomes  of  such  a  character  that  it  can  only  be  relieved 
by  death. 

In  other  patients  the  first  attack  of  dyspnoea  is  also  the  last.  It 
cannot  be  relieved  by  any  treatment  and  coutinnes  up  to  the  time  of 
the  patient's  death. 

A  catarrhal  hronckitis  with  cough  and  expectoration  is  sometimes 
an  annoying  symptom.  The  cough  fatigues  the  patient,  and  it  is 
difficult  to  control  it. 

Loss  of  apiyetite,  nausea  and  vomiting  are  frequent  symptoms. 
When  they  do  not  already  exist  it  is  easy  to  cause  them  hj  the  use  of 
improper  drugs. 

The  heart  is  verj-  often  affected.  The  disease  of  the  kidneys  after 
a  time  produces  hypertrophy  of  the  left  ventricle.  This  does  no  harm 
until  the  time  comes  when  the  heart's  action  fails  in  spite  of  the 
hypertrophy,  then  the  dyspnoea  and  dropsy  follow. 

Chronic  endocarditis,  chronic  myocarditis,  and  dilatation  of  the 
ventricles  are  associated  with  chronic  nephritis  in  two  ways :  they 
may  cause  a  chronic  congestion  or  degeneration  of  the  kidney  which 
is  afterward  followed  by  a  nephritis ;  or  the  heart  disease  and  kid- 
ney disease  are  developed  in  the  same  person,  neither  one  of  them 
secondary  to  the  other.  In  these  patients  it  is  by  no  means  easy  to 
tell  how  much  of  the  dropsy,  the  dyspnoea,  and  the  loss  of  nutrition 
belongs  to  the  heart  disease  and  how  much  to  the  nephritis. 

COUESE   OP  THE  DISEASE. 

There  is  hardly  any  limit  to  the  variations  of  the  disease,  but  the 
most  constant  symptoms  are  anaemia,  dropsy,  and  albumin  in  the 
urine. 

The  following  are  some  of  the  ordinary  examples  of  this  form  of 
nej)hritis : 

1.  There  are  cases  in  which  the  symptoms  are  nearly  continuous. 
The  patients  begin  with  ansemia,  headache,  disturbances  of  digestion, 
and  a  little  dropsy.  No  one  of  these  symptoms  is  at  first  very 
marked ;  the  patient  is  not  in  bed,  he  does  not  feel  very  sick,  but  even 
at  this  time  the  urine  contains  a  large  quantity  of  albumin.  As  the 
weeks  and  months  go  on  all  the  symptoms  grow  worse :  the  anaemia 
is  more  profound,  the  headaches  and  disturbances  of  digestion  more 
troublesome,  the  dropsy  involves  more  of  the  subcutaneous  tissue 
and  the  serous  cavities  so  that  the  patient  becomes  more  and  more 
helpless.  There  may  be  intercurrent  attacks  of  acute  uraemia  with 
contraction  of  the  arteries,  or  loss  of  eyesight,  or  a  troublesome  bron- 


CHRONIC   PRODUCTIVE  NEPHRITIS   WITH    EXUDATION.  83 

cliitis.  The  ordinary  duration  of  this  form  of  the  disease  is  from 
one  to  three  years.  The  jjatients  die  with  the  most  extreme  dropsy, 
or  in  the  state  of  chronic  uraemia,  or  both  these  conditions  exist  to- 
gether. 

2.  There  are  cases  in  which  the  anaemia,  the  drox)sy,  and  the  dysp- 
noea come  on  in  attacks  which  last  for  weeks  or  months.  Between 
the  attacks  the  patients  are  comparatively  well,  often  able  to  work, 
although  the  urine  always  contains  albumin.  These  patients  often 
go  on  for  a  number  of  years,  better  in  the  summer  and  worse  in  the 
winter.  But  each  successive  attack  is  more  serious  than  the  preced- 
ing, and  finally  there  comes  an  attack  from  which  the  patient  does  not 
recover. 

3.  There  are  cases  in  which  a  number  of  years  before  death  the 
patients  have  an  attack  of  acute  or  subacute  nephritis  with  anaemia, 
dyspnoea,  dropsy,  albumin  in  the  urine,  and  all  the  usual  symptoms. 
From  this  they  apparently  recover  completely  and  seem  to  be  in 
their  ordinary  health.  The  urine  continues  to  contain  a  little  albu- 
min, or  on  some  days  the  albumin  disappears  altogether.  From  year 
to  year  the  specific  gravity  slowly  falls.  The  exudation  from  the 
blood-vessels  of  the  kidne.ys  stops,  but  the  chronic  productive  inflam- 
mation of  the  kidneys  continues.  Finally,  after  exposure,  with  an 
accident,  with  a  pneumonia,  or  without  discoverable  cause,  all  the 
symptoms  of  a  subacute  nephritis  are  rather  suddenly  developed,  and 
the  patient  soon  dies. 

4.  There  are  cases  which  for  years  have  no  symptoms  except  pal- 
lor of  the  skin  and  mucous  membranes,  and  urine  of  low  specific 
gravity  which  habitually  contains  a  moderate  quantity  of  albumin. 
These  patients  must  not  be  confounded  with  cases  of  simple  anaemia, 
nor  with  those  of  persistent  albuminuria  without  kidney  disease. 
The  diagnosis  is  sometimes  quite  difficult.  The  prognosis  in  these 
patients  depends  upon  the  specific  gravity  of  the  urine.  If  it  is  con- 
stantly below  1.010  the  jjrognosis  is  bad,  no  matter  how  well  the  pa- 
tients may  feel. 

5.  There  are  cases  in  which  the  first  symptom  is  the  attack  of 
spasmodic  dyspnoea.  This  may  continue  and  other  renal  symptoms 
rapidly  develop.  More  frequently,  however,  the  dyspnoea  is  palli- 
ated or  relieved  by  treatment.  The  patient  then  goes  on  for  months 
or  years  with  occasional  attacks  of  dyspnoea,  each  one  more  severe 
and  harder  to  control,  until  finally  other  renal  symptoms  appear. 

6.  There  are  the  cases  complicated  with  endocarditis,  myocarditis, 
or  dilated  heart.  In  these  patients  we  have  the  association  of  cardiac 
and  renal  symjjtoms,  either  one  predominating. 

7.  There  are  cases  in  which  all  the  symptoms  disappear,  and  the 


84  DELAPEELD — DISEASES  OF  THE  KIDNEYS. 

urine  returns  to  its  natural  condition.  If  tliis  improvement  continues 
for  a  number  of  years  it  seems  probable  that  the  nephritis  has  come 
to  a  standstill,  and  that  enough  kidney  tissue  has  been  left  unim- 
paired to  carry  on  the  functions  of  the  organ. 

Teeatment. 

In  the  second  and  third  group  of  cases  just  described  the  attacks 
are  of  acute  or  subacute  character.  The  conditions  calling  for  treat- 
ment are : 

The  nephritis ; 

The  albuminuria; 

The  dropsy ; 

The  headache  and  sleeplessness ; 

The  nausea  and  vomiting ; 

The  contraction  of  the  arteries ; 

The  anaemia; 

The  dysjjnoea. 

For  the  nephritis  the  patient  should  be  kept  in  bed  and  placed  on 
a  fluid  diet.  He  should  have  a  hot  pack  twice  a  day,  once  a  day,  or 
every  other  day,  as  he  will  bear  it.  The  most  useful  drugs  are :  mor- 
phine in  very  small  doses,  digitalin  gr.  7^,  and  aconite  tt^  i.-iij. 

The  quantity  of  albumin  in  the  urine  can  be  diminished  by  the  hot 
pack  and  by  the  use  of  digitalin  gr.  y^o  four  times  a  day. 

The  dropsij  is  favorably  affected  by  the  hot  pack.  It  can  be  sen- 
sibly diminished  by  cathartics,  of  which  elaterium  is  jjerhaps  the 
best.  But  the  effect  of  cathartics  is  temporary,  and  their  administra- 
tion cannot  often  be  repeated. 

For  many  patients  digitalis  in  some  form  is  the  most  useful  drug 
for  the  dropsy,  and  it  can  be  continued  without  injury  for  weeks  and 
months.  Favorable  results  are  reported  from  the  use  of  lactate  of 
strontium  in  30-grain  doses  four  times  a  day,  and  from  diuretin  in 
5-grain  doses  three  times  a  day.  In  some  patients  caffeine,  conval- 
laria,  or  strophanthus  wiU  answer  better  than  digitalis. 

If  there  is  much  fluid  in  the  serous  cavities  it  should  be  drawn  off 
with  the  aspirator.  If  the  dropsy  of  the  subcutaneous  connective 
tissue  is  excessive  the  skin  is  to  be  pricked  and  the  fluid  allowed  to 
drain  off. 

The  headache  and  sleej^lessness  may  exist  with  or  without  contrac- 
tion of  the  arteries.  If  the  arteries  are  not  contracted,  morphine  in 
very  small  doses,  codeine,  or  the  bromides  can  be  used.  If  the  arteries 
are  contracted  morphine  in  larger  doses  and  chloral  are  the  best  drugs. 

The  nausea  and  vomiting  are  controlled  by  the  milk  diet,  or  it  may 


CHRONIC  PRODUCTIVE  NEPHRITIS  WITH   EXUDATION.  85 

be  necessary  to  add  an  alkali  to  the  milk,  or  to  use  peptonized  milk  or 
kumyss. 

Contraction  of  the  Arteries. — The  character  of  the  radial  pulse  and 
the  heart's  action  are  to  be  constantly  watched.  We  do  not  wait 
for  the  dyspnoea,  or  vomiting,  or  convulsions  to  make  their  appear- 
ance, but  as  soon  as  the  pulse  shows  an  increased  tension  we  begin 
with  nitroglycerin,  chloral  hydrate,  morphine,  or  potassium  iodide. 
It  is  to  be  remembered  that  morphine  in  considerable  doses  can  only 
be  given  to  patients  with  this  form  of  nephritis  when  the  arteries  are 
contracted.  At  all  other  times  it  is  very  easy  to  have  dangerous  and 
even  fatal  results  with  any  preparation  of  opium. 

The  ancemia  of  chronic  nephritis  does  not  behave  like  simple 
ansemia.  Iron  is  not  a  specific  for  it,  although  it  may  be  of  service. 
The  greatest  improvement  in  the  ansemia  is  effected  by  the  subsidence 
of  the  nephritis. 

The  dyspnoea  is  dependent  either  uj^on  contraction  of  the  arteries 
or  upon  dropsy.  The  treatment  for  it,  therefore,  is  either  the  treat- 
ment of  dropsy  or  the  treatment  of  contraction  of  the  arteries. 

In  these  two  groups  of  cases  treatment  carried  on  in  these  ways 
is  often  very  satisfactory.  All  the  symptoms  subside  and  disappear. 
But  it  must  be  remembered  that  the  kidneys  have  become  changed 
in  their  structure,  that  a  chronic  productive  nephritis  still  continues, 
that  relapses  and  exacerbations  are  to  be  expected. 

As  the  symptoms  subside  the  patient  gets  back  to  a  solid  diet,  is 
out  of  bed  and  then  out  of  doors.  If  it  is  possible  for  him  to  spend 
the  next  two  years  in  a  warm  climate  where  he  can  lead  an  out-of- 
door  life,  the  probabilities  of  permanent  improvement  will  be  much 
greater. 

In  the  first  set  of  cases,  those  in  which  the  symptoms  continue 
and  get  steadily  worse,  treatment  is  very  unsatisfactory.  We  try  the 
measures  that  have  just  been  described,  but  they  are  of  no  avail. 
We  cannot  even  alleviate  symptoms,  the  drugs  do  not  help  at  all. 
After  a  time  it  becomes  evident  that  there  is  no  use  in  continuing 
plans  of  treatment  which  do  nothing,  and  we  employ  very  little  treat- 
ment. 

The  fourth  set  of  cases  have  no  acute  attacks,  no  great  change  in 
the  general  health,  nothing  but  the  ansemia  and  the  changes  in  the 
urine.     The  management  of  these  cases  requires  much  judgment. 

The  x>atients  should  have  a  liberal  and  varied  diet  and  yet  every 
form  of  indigestion  is  to  be  guarded  against.  They  do  best  if  they  can 
live  in  a  warm  climate  all  the  year  round.  But  even  in  an  unfa- 
vorable climate  they  need  out-of-door  exercise.  The  drugs  indicated 
are  those  for  the  relief  of  indigestion,  and  the  preparations  of  iron. 


86  DELAFIELD — DISEASES   OF  THE   KIDNEYS. 

The  patients  who  begin  with  attacks  of  dyspnoea,  without  other 
renal  symptoms,  can  often  be  relieved  and  enabled  to  work  for  a 
number  of  years.  The  dyspnoea  is  associated  with  a  pulse  of  high 
tension;  if  we  can  relieve  this  the  dyspnoea  disappears.  The  best 
drugs  for  this  purpose  are  nitroglycerin,  chloral  hydrate,  and  po- 
tassium iodide. 

In  the  cases  with  chronic  endocarditis,  myocarditis,  or  dilatation 
of  the  ventricles,  the  management  of  the  heart's  action  becomes  a 
matter  of  great  importance. 

Chronic  Productive  Nephritis  without  Exudation. 

Definition. 

A  chronic  inflammation  of  the  kidney  attended  with  a  new  growth 
of  connective  tissue  in  the  stroma,  permanent  changes  in  the  glom- 
eruli, degeneration  of  the  renal  epithelium,  and  sometimes  changes  in 
the  walls  of  the  arteries. 

Synonyms. — Chronic  Bright' s  disease;  Cirrhosis  of  the  kidney; 
Granular  degeneration ;  Interstitial  nephritis ;  Chronic  indurative  ne- 
phritis ;  The  arterio-sclerotic  kidney. 

Etiology. 

While  this  form  of  nephritis  is  especially  common  in  persons  over 
forty-five  years  old,  it  is  by  no  means  rare  in  young  adults,  and  is 
occasionally  seen  in  children. 

It  seems  to  be  caused  by  chronic  alcoholism,  lead  poisoning, 
gout,  and  by  the  same  conditions  as  those  which  cause  emphysema, 
endocarditis,  and  cirrhosis  of  the  liver.  It  follows  chronic  conges- 
tion of  the  kidney,  hydronephrosis,  and  chronic  pyelitis. 

MoEBiD  Anatomy. 

The  Kidneys. — The  larger  number  of  the  affected  organs  are  found 
after  death  to  be  diminished  in  size ;  the  two  kidneys  together  may 
not  weigh  more  than  two  ounces.  The  capsules  are  adherent;  the 
surfaces  of  the  kidneys  are  roughened  or  nodular,  the  cortex  is  thin 
and  of  a  red  or  gray  color. 

A  considerable  number  of  these  kidneys,  however,  do  not  differ  in 
their  size  or  appearance  from  normal  kidneys,  except  that  their 
capsules  are  adherent  and  their  surfaces  roughened. 

Occasionally  the  kidneys  are  large,  weighing  together  from  16  to 


CHRONIC  PRODUCTIVE  NEPHRITIS  WITHOUT  EXUDATION. 


87 


32  ounces,  witli  smooth  or  nodular  surfaces,  and  a  cortex  of  red,  gray, 
or  white  color. 

If  the  nephritis  follows  chronic  congestion,  the  kidneys  remain 
hard,  but  the  cortex  becomes  thinned,  the  capsules  adherent,  and  the 
surface  roughened. 

There  is  a  growth  of  new  connective  tissue  in  the  cortex  and  also 
in  the  pyramids,  which  becomes  more  and  more  extensive  as  the  dis- 
ease goes  on.  In  the  cortex  the  new  tissue  follows  the  distribution 
of  the  normal  subcapsular  areas  of  connective  tissue,  is  in  the  form  of 


eST^' 


Fig.  19.— Vertical  Section  of  the  Cortex.    Chronic  Nephritis  without  Exudation. 


In 


irregular  masses,  or  is  distributed  diffusely  between  the  tubes 
the  pyramids  the  growth  of  new  connective  tissue  is  diffuse. 

The  tubes,  both  in  the  cortex  and  pyramids,  undergo  marked 
changes.  Those  included  in  the  masses  of  connective  tissue  are 
diminished  in  size,  their  epithelium  is  flattened,  some  contain  cast 
matter,  many  are  obliterated.  The  tubes  between  the  masses  of  new 
connective  tissue  are  more  or  less  dilated ;  their  epithelium  is  flat- 
tened, cuboidal,  swollen,  degenerated,  or  fatty.  The  dilatation  of 
the  tubes  may  reach  such  a  x)oint  as  to  form  cysts  of  some  size,  which 
contain  fluid,  or  coagulated  matter.  These  cysts  follow  the  lines  of 
systems  of  tubes,  or  are  situated  near  the  capsules. 


88 


DELATIELD — DISEASES   OF  THE   KIDNEYS. 


Of  the  ghmendi  a  certain  number  remain  of  normal  size,  but  with, 
the  tnft  cells  swollen  or  multiplied.  Many  others  are  found  in  all 
stages  of  atrophy  and  of  change  into  connective  tissue.  The  atrophy 
seems  to  depend  partly  on  the  growth  of  tuft  cells  and  intra-capillary 
cells,  partly  on  the  thickening  of  the  capsules,  partly  on  the  occlusion 
of  the  arteries.  If  the  chronic  nephritis  follows  chronic  congestion  of 
the  kidneys  the  glomeruli  remain  large,  with  an  increased  growth 
of  tuft  cells,  or  they  become  atrophied,  but  with  the  dilatation  of  the 


Fig.  20.— Cortex  Tubes.    Chronic  Nephritis  without  Exudation. 

capillaries  still  evident.  The  capillaries  of  the  glomeruli  may  be  the 
seat  of  waxy  degeneration.  The  arteries  exhibit  the  same  changes 
as  have  already  been  described  in  speaking  of  chronic  exudative 
nephritis. 

Complicating  Lesions. 

Heart. — Hypertrophy  of  the  left  ventricle  of  the  heart  is  fre- 
quently caused  by  exudative  nephritis,  but  much  more  frequently  by 
chronic  nephritis  without  exudation.  It  must  be  admitted,  how- 
ever, that  such  an  hypertrophy,  although  frequent,  is  not  constant. 


CHEONIC   PRODUCTIVE  NEPHEITIS  WITHOUT  EXUDATION. 


89 


and  that  with  both  exudative  and  non-exudative  nephritis  there  may 
be  no  change  in  the  wall  of  the  left  ventricle.  The  hypertrophy  of 
the  wall  of  the  ventricle  may  after  a  time  be  succeeded  by  dilatation, 
or  chronic  degeneration,  or  myocarditis. 

Chronic  endocarditis  is  often  associated  with  this  form  of  nephritis, 
apparently  both  lesions  being  produced  by  the  same  causes.  It  may 
also  happen  that  chronic  endocarditis  causes  first  chronic  congestion 
of  the  kidney  and  then  chronic  nephritis  without  exudation. 


Fig.  21.— Cortex  Tubes.    Acute  Exacerbation  in  Chronic  Nephritis  without  Exudation. 

Lungs. — Pulmonary  emphysema  and  cirrhosis  of  the  liver  are  fre- 
quently associated  with  chronic  nephritis. 

Arteries. — One  of  the  most  important  of  the  complicating  lesions 
is  chronic  endarteritis.  The  relationship  between  endarteritis  or, 
more  prox)erly  speaking,  arteritis  and  nephritis,  and  the  ways  in  which 
they  are  associated  together  are  not  as  fully  understood  as  they  should 
be.  The  principal  reason  for  this  is  the  failure  to  recognize  the  fact 
that  chronic  inflammation  of  the  walls  of  the  arteries  is  just  as  much 
a  disease  as  chronic  endocarditis,  or  emjihysema,  or  cirrhosis  of  the 
liver. 


90  DELATIELD— DISEASES   OF  THE  KIDNEYS. 

Arteritis. 

Unquestionablj  arteritis  is  more  often  seen  associated  with  other 
diseases  than  by  itself.  It  must  also  be  admitted  that  it  is  of  such 
frequent  occurrence  in  old  persons  that  it  is  natural  to  think  of  it  as 
a  senile  change.  Still  farther,  the  use  of  such  names  as  arterio-capil- 
lary  fibrosis  and  arterio-sclerosis  have  helped  to  prevent  us  from 
classing  arteritis  with  the  other  chronic  productive  inflammations. 


Fig.  22.— An  Atrophied  Glomerulus.    Chronic  Nephritis  without  Exudation. 

Chronic  inflammation  may  involve  the  entire  aortic  system  of 
arteries,  or  it  may  be  confined  to  a  part  of  that  system. 

If  only  the  arteries  in  some  one  part  of  the  body  are  involved,  then 
in  that  part  of  the  body  the  blood  supply  is  irregular  or  cut  off,  the 
diseased  artery  may  become  dilated,  or  it  may  rupture. 

If  a  large  part  of  the  aortic  system  of  arteries  is  involved,  then 
the  patients  suffer  from  symptoms  which  seem  to  depend  partly  upon 
the  changes  in  the  arteries,  partly  upon  attacks  of  contraction  of  the 
arteries,  partly  upon  hypertrophy  of  the  left  ventricle  of  the  heart 


CHRONIC   PRODUCTIVE  NEPHRITIS  WITHOUT  EXUDATION. 


91 


and  heart  failure,  partly  upon  the  obstruetion  to  the  passage  of  blood 
through  the  cerebral  arteries. 

The  clearest  idea  of  general  arteritis  as  a  disease  is  to  be  obtained 
by  observing  it  in  persons  not  over  forty  years  old,  who  have  no  com- 
plicating lesions. 

At  first  for  a  number  of  years  these  patients  suffer  only  from  im- 
paired nutrition,  a  disposition  to  become  anaemic,  and  attacks  of 
dyspnoea.     It  can  be  seen  and  felt  that  the  walls  of  the  temporal  and 


Fig.  23.— An  Atrophied  Glomerulus.    Chronic  Nephritis  without  Exudation. 


radial  arteries  are  thickened  and  that  the  left  ventricle  of  the  heart  is 
hypertrophied.  At  the  times  when  the  patient  has  dyspnoea  the  ten- 
sion of  the  pulse  is  much  increased. 

For  a  considerable  length  of  time  the  nutrition  and  the  ansemia 
can  be  imjjroved  by  climate  and  by  diet.  The  attacks  of  dyspnoea 
can  be  controlled  by  the  drugs  which  dilate  the  arteries.  But  sooner 
or  later  tlie  i)atientH  get  worse.  Some  of  them  get  up  a  dyspnoea  that 
cannot  be  controlled,  the  action  of  the  hyi)ertrophied  heart  fails,  and 
the  patients,  after  suffering  for  weeks  or  months  with  the  most  dis- 


92 


DELATIELD — DISEASES  OF  THE   KIDNEYS. 


tressing  symptoms,  die.  In  other  cases  death  takes  place  with  cere- 
bral symptoms — sudden  unconsciousness,  or  aphasia,  or  hemiplegia. 
After  the  death  of  these  patients  no  lesions  of  any  consequence  are 
found  except  the  changes  produced  by  chronic  inflammation  of  the 
walls  of  the  arteries. 

It  is  evident  that  the  symptoms  and  death  of  these  patients  are 
due  to  the  changes  in  the  arteries,  that  the  disease  from  which  they 
have  suffered  is  chronic  arteritis.  But  it  is  also  evident  that  their 
symptoms — loss  of  nutrition,  anaemia,  contraction  of   the   arteries, 


Fig.  24.— An  Atrophied  Glomerulus.    Chronic  Nephritis  without  Exudation. 


hypertrophy  of  the  left  ventricle,  dyspnoea,  heart  failure,  uncon- 
sciousness, aphasia,  hemixjlegia — are  also  the  symptoms  of  chronic 
nephritis. 

Still  further  we  find  that  many  patients  with  these  symptoms  do 
have  both  arteritis  and  nephritis.  In  any  given  case  with  these 
symptoms,  therefore,  it  is  a  matter  of  importance  to  determine 
whether  the  patient  has  arteritis  alone,  or  nephritis  alone,  or  both 
diseases  at  the  same  time. 


CHRONIC   PRODUCTIVE   NEPHRITIS   WITHOUT  EXUDATION. 


93 


Patients  wlio  have  chronic  nephritis  are  more  liable  than  are  other 
persons  to  attacks  of  pericarditis,  bronchitis,  and  gastric  catarrh. 

Symptoms. 

Tlie  Urine. — The  typical  urine  of  chronic  non-exudative  nephritis 
is  a  urine  increased  in  quantity,  of  a  specific  gravity  of  about  1.010, 
containing  a  diminished  quantity  of  urea,  without  albumin  or  casts, 


Fig.  25.— An  Atrophied  Glomerulus.     Chronic  Nephritis  without  Exudation. 

or  with  a  trace  of  albumin  and  very  few  casts.  But  exacerbations  of 
the  nephritis  and  changes  in  the  circulation  may  for  a  time  consider- 
ably increase  the  quantity  of  albumin  and  the  number  of  casts. 

Very  imi)ortant  modifications  of  the  urine,  however,  are  of  ordi- 
nary occurrence.  It  is  quite  possible  with  nephritis  of  this  type  far 
advanced  to  have  urine  not  below  1.023  in  specific  gravity  and  with- 
out albumin  or  casts.  When  one  sees  this  urine  during  life  and  then 
the  kidneys  after  death  it  is  difficult  to  understand  how  they  can  be- 
long to  each  other. 


94 


DELATTELD — DISEASES   OE   THE   KIDXEYS. 


On  tlie  otlier  liand  there  are  cases  in  wliicli  the  specific  gravity  of 
the  urine  falls  ahnost  to  1.000,  either  with  or  without  waxT  degenera- 
tion of  the  blood-vessels.  In  some  cases  the  quantity  of  urine  is  very 
much  increased — several  quarts  in  the  twenty-four  hours.  During 
the  attacks  of  contraction  of  the  aiieries,  to  which  these  patients  are 
liable,  the  urine  may  be  diminished  to  a  few  ounces  or  even  sup- 
pressed. 

Cerebi'ol  Symptoms. — In  a  great  many  of  the  cases  cerebral  symp- 
toms  are   developed  at  some  time   in  the   course   of  the   disease. 


Fig.  26.— An  Atrophied  Glomerulus.    Chronic  Nephritis  without  Exudation. 


Headache  and  sleeplessness  are  often  present,  the  headache  some- 
times so  severe  and  continuous  that  the  patient  is  nearly  maniacal. 
Instead  of  the  headache  there  may  be  neuralgic  pains  in  different 
parts  of  the  body. 

Muscular  twitchings  and  general  compulsions  are  much  more  seri- 
ous. They  may  be  early  symptoms,  or  not  occur  until  late  in  the 
disease. 

Hemiplegia,  with  or  without  aphasia,  may  be  the  first  symptom 


CHEONIC   PEODUCTITE   XEPHEITIS   WIXHOUT  EXTHDATIOX.  9o 

to  call  attention  to  the  nephritis,  or  mar  not  occur  until  later  in  the 
disease.  The  invasion  of  the  hemiplegia  is  sudden  and  is  usually  ac- 
companied by  coma.  There  is  loss  of  motion  alone,  or  of  both  mo- 
tion and  sensation.  The  hemifjlegia,  aphasia,  and  coma  may  con- 
tinue up  to  the  time  of  the  patient's  death,  or  disappear  after  a  few 
hours  or  days.  In  the  latter  case  the  patient  may  have  several  such 
attacks.  These  attacks  have  been  ascribed  to  localized  oedema  of  the 
brain.  In  the  cases  which  I  have  seen  there  were  no  changes  in  the 
brain  tissue,  but  the  cerebral  arteries  were  damaged  by  chronic 
arteritis. 

Delirium,  mild  or  violent,  stupor,  and  coma  may  come  on  in  sud- 
den attacks,  or  be  developed  slowly  and  gradually. 

When  these  cerebral  symptoms  come  on  in  attacks  the  x^u^lse  is  of 
high  tension,  the  temperature  is  raised,  and  the  jjatients  are  said 
to  suffer  from  acute  urtemia.  Yery  often  they  recover  from  a 
number  of  these  attacks.  In  the  fatal  attacks  the  pulse  often  loses 
its  tension  and  becomes  rapid  and  feeble ;  the  patients  die  comatose 
vdth  a  feeble  heart. 

Instead  of  such  acute  attacks  of  cerebral  symjitoms,  delirium  and 
stupor  may  come  on  gradually  in  persons  far  advanced  in  their  ne- 
phritis. The  temperature  is  then  apt  to  be  below  the  normal  and  the 
pulse  is  rapid  and  feeble. 

Temporary  blindness,  neuro-retinitis,  or  nephritic  retinitis  are  de- 
veloped in  a  moderate  number  of  the  patients. 

Chronic  bronchitis  and  emphysema  very  frequently  exist  and  their 
symptoms  often  form  a  large  x^art  of  the  clinical  history. 

Attention  has  already  been  called  to  the  large  share  that  chronic 
arteritis  may  have  in  the  xji'oduction  of  some  of  the  renal  symptoms. 

The  Heart. — The  left  ventricle  of  the  heart  regularly  becomes 
hypertrophied  after  the  nephritis  has  lasted  for  several  months.  The 
disposition  to  hypertrophy  is,  I  think,  rendered  greater  by  repeated 
attacks  of  contraction  of  the  arteries  and  by  complicating  arteritis. 
The  hypertrophy  is  usually  easily  made  out.  The  x>atient  remains 
unconscious  of  its  existence,  or  has  disturbances  of  sensation  and  pal- 
pitation. As  the  disease  goes  on  the  hypertrophied  heart  may  become 
feeble,  and  then  dyspnoea  and  the  other  evidences  of  feeble  circulation 
make  their  appearance. 

In  the  same  way  the  comjjlicating  endocarditis,  which  so  often 
exists,  may  give  no  trouble  until  the  valves  are  a  good  deal  changed, 
or  the  ventricles  dilated,  or  the  heart's  action  altered,  or  the  artenes 
contracted ;  then  the  circulation  is  interfered  with,  and  the  results  of 
venous  congestion  of  different  jjarts  of  the  Ijody  show  themselves, 

Dyspnoia  is  a  frequent  symptom,  often  the  fii'st  symptom  noticed 


96  DELAPIELD — DISEASES   OF  THE  KIDNETS. 

by  the  patient.  It  is  a  spasmodic  dyspncea  coming  on  in  attacks, 
wMcli  last  for  minutes,  hours,  or  days.  It  is  made  worse  by  bodily 
or  mental  exertion,  or  by  tlie  recumbent  position.  It  does  not  resemble 
bronchial  asthma.  It  is  apparently  due  to  the  association  of  changes 
in  the  arteries  and  heart.  It  cannot  be  distinguished  from  the  dysp- 
noea which  is  caused  by  arteritis  without  nephritis.  With  contrac- 
tion of  the  arteries  alone,  or  with  a  feeble  heart  alone,  no  dyspnoea 
may  exist ;  but  if  the  contraction  of  the  arteries  be  so  great  that  the 
hypertrophied  heai-t  cannot  overcome  the  obstruction,  or  if  with  con- 
traction of  the  arteries  the  heai-t  becomes  dilated  or  feeble,  then  the 
attacks  of  dyspnoea  begin.  At  first  the  attacks  are  not  severe  and  are 
of  short  duration,  but  if  the  mechanical  conditions  which  cause  them 
cannot  be  controlled,  they  become  longer  and  more  distressing. 

The  stomach  may  continue  to  perform  its  functions  fairly  well,  but 
more  often  there  is  gastric  indigestion,  gastric  catarrh,  or  spasmodic 
vomiting. 

Dropsy  as  a  rule  is  absent  with  non-exudative  nephritis,  unless  it 
is  complicated  by  chronic  endocarditis,  by  cirrhosis  of  the  liver,  or  by 
the  disturbances  of  circulation  which  come  on  later  in  the  nephritis. 

Profuse  bleeding  from  the  pelvis  of  atrophied  kidneys  is  some- 
times seen.  In  all  cases,  after  a  time,  the  nephritis  exerts  its  effects 
upon  the  nutrition  of  the  patient,  and  the  flesh  and  strength  are 
diminished.  On  the  other  hand,  the  patients  do  not  usually  become 
so  pale  as  they  do  with  an  exudative  nephritis. 

COUESE  OF   THE  DISEASE. 

It  is  characteristic  of  the  chronic  productive  inflammations  of  the 
lungs,  the  heart,  the  arteries,  the  liver,  and  the  kidneys  that,  while 
they  often  exist  as  serious  and  fatal  diseases,  they  may  also  exist  as 
lesions  and  yet  do  not  interfere  mth  long  life  and  apparent  good 
health.  This  seems  to  depend,  at  least  in  part,  on  the  rapidity  with 
which  the  inflammatory  changes  in  these  different  parts  of  the  body 
are  developed.  If  the  development  is  slow  enough,  the  functions  of 
the  organ  continue  to  be  performed  in  spite  of  the  new  growth  of  con- 
nective tissue. 

We  have  to  admit  that  in  all  cases  of  chronic  non-exudative  ne- 
phritis a  period  of  weeks,  or  months,  or  years  elapses  during  which 
the  changes  in  the  kidney  are  slowly  going  on,  and  yet  the  patients 
seem  well  and  are  not  aware  that  ih&j  have  any  disease.  How  far 
the  nephritis  can  advance  and  how  many  years  it  can  exist  before  the 
symptoms  of  it  appear,  it  is  diificult  to  say.  We  see  a  great  many 
different  stages  in  the  development  of  the  nephritis  in  persons  who 
die  from  other  diseases  and  have  never  given  any  renal  symptoms. 


/  CHRONIC  PRODUCTIVE   NEPHRITIS  WITHOUT  EXUDATION.  97 

The  nephritis  is  of  slow  development,  gradually  altering  the 
structure  of  the  kidney  more  and  more,  so  that  we  should  expect  that 
the  symptoms  of  the  nephritis  would  also  be  developed  gradually. 
This  is  very  often  the  case,  but  quite  as  often  the  nephritis  will  ad- 
vance without  symptoms  up  to  a  certain  point  and  then  the  patient 
suddenly  becomes  ill. 

A.  Gases  with  Slow  Development  of  Symptoms. — Of  the  patients 
in  whom  the  symptoms  are  gradually  developed  we  may  distinguish : 

1.  Patients  who  gradually  develop  hypertrophy  of  the  left  ventri- 
cle of  the  heart,  with  a  lowering  of  the  specific  gravity  of  the  urine, 
and  a  pulse  that  is  easily  made  too  tense,  otherwise  their  health  is 
good.  We  often  watch  these  persons  for  many  years,  expecting  other 
renal  symptoms.  But  the  symptoms  do  not  come,  and  the  patients 
die  of  some  other  disease. 

2.  Patients  who  have  digestive  disturbances,  and  gradual  loss  of 
flesh  and  strength.  The  urine  is  of  low  specific  gravity  and  increased 
quantity,  or  the  specific  gravity  and  quantity  remain  almost  normal ; 
often  from  time  to  time  there  are  traces  of  albumin  and  a  few  hyaline 
casts.  These  patients  are  often  very  puzzling.  From  year  to  year 
they  slowly  get  more  feeble  and  more  emaciated ;  the  digestive  dis- 
turbances are  sometimes  better  and  sometimes  worse.  Occasionally 
there  is  an  interval  of  great  improvement  so  that  the  patients  think 
they  have  entirely  recovered.  As  the  disease  lasts  a  long  time  the 
patients  are  apt  to  see  a  number  of  physicians  and  get  a  number  of 
opinions,  for  the  diagnosis  is  really  a  difiicult  one.  Some  of  the  pa- 
tients die  from  intercurrent  diseases,  but  others  go  on  and  die  simply 
exhausted  with  nothing  but  the  chronic  nephritis. 

3.  Patients  who  for  months  or  years  have  attacks  of  spasmodic 
dyspnoea  and  between  these  attacks  are  comparatively  well.  The  pa- 
tients are  usually  over  forty  years  old.  The  attacks  of  dyspnoea  are 
apt  to  come  on  in  the  early  morning  and  go  off  later  in  the  day. 
Often  chronic  arteritis,  or  chronic  endocarditis,  exists  at  the  same 
time.  For  a  while  the  attacks  of  dyspnoea  can  be  relieved,  and  the  pa- 
tients are  capable  of  mental  and  physical  exertion  and  feel  quite  con- 
fident of  recovery.  But  as  the  attacks  of  dyspnoea  recur  they  last 
longer  and  are  harder  to  relieve.  Finally  comes  the  time  when  the 
dyspnoea  cannot  be  relieved.  It  lasts  day  and  night,  the  patients 
cannot  lie  down,  the  scrotum  and  legs  become  oedematous,  and  death 
hardly  comes  soon  enough  to  relieve  their  distress. 

4.  Patients  who  have  symptoms  progressing  for  several  years.  At 
first  vomiting,  or  headache,  or  neuralgic  pains.  Then  dyspnoea,  a 
little  dropsy  of  the  legs,  and  loss  of  flesh  and  strength.  Finally 
death  from  exhaustion,  or  with  an  attack  of  convulsions,  or  in  coma. 

Vol.  I.— 7 


98  DELATIELD — ^DISEASES  OF  THE  KIDNEYS. 

5.  Patients  in  wliom  the  symptoms  come  on  in  attacks,  each  at- 
tack worse  than  the  preceding,  and  the  general  health  more  and  more 
impaired  between  the  attacks.  During  the  attacks  there  are  head- 
ache, sleeplessness,  delirium,  stupor,  coma,  convulsions,  dyspnoea, 
vomiting — sometimes  one,  sometimes  another  the  prominent  symp- 
tom. The  tension  of  the  pulse  is  considerably  increased.  The  urine 
is  of  low  specific  gravity  and  often  contains  a  little  albumin.  Be- 
tween the  attacks  the  x)atient8  at  first  seem  to  be  fairly  well,  but  later 
they  gradually  lose  flesh  and  strength.  The  urine  between  the  attacks 
is  of  low  specific  gravity  and  contains  little  or  no  albumin.  The  pa- 
tients finally  die  in  one  of  the  attacks. 

B.  Cases  ivitli  Rapid  Development  of  Symptoms. — Of  the  patients 
who  are  apparently  in  their  ordinary  health  until  there  is  a  violent  in- 
vasion of  symptoms,  we  may  distinguish  those  in  whom  the  attack 
seems  to  be  precipitated  by  an  injury  or  an  intercurrent  disease,  and 
those  in  whom  it  comes  on  without  discoverable  cause.  In  either 
case  the  attack  regularly  takes  the  form  of  cerebral  symi:)toms,  or  of 
dyspnoea,  or  of  vomiting,  or  of  sudden  death.  During  these  attacks 
the  tension  of  the  pulse  is  high,  the  urine  is  diminished  in  quantity 
or  sujjpressed  and  often  contains  a  little  albumin. 

1.  The  cerebral  symptoms  are:  general  convulsions,  coma,  hemi- 
plegia, and  aphasia.  The  compulsions  come  on  suddenly,  they  are  re- 
peated several  times,  between  them  the  patients  are  unconscious. 
Many  of  the  patients  die  with  the  con\Tilsions,  but  a  few  recover.  We 
are  apt  to  see  these  persons  for  the  first  time  while  the  convulsions 
are  going  on,  and  are  told  by  their  friends  that  they  were  in  their 
ordinary  health  until  the  convulsions  began. 

The  coma  is  developed  in  the  same  rapid  way.  The  patient  is 
found  in  bed,  in  a  room,  or  in  the  street,  at  first  stui)id  and  muttering 
incoherently,  then  comjjletely  comatose.  From  this  coma  they  do 
not  emerge,  but  go  on  and  die  in  a  few  hours  or  days. 

The  hemiplegia  is  like  that  with  a  clot  or  with  an  obstructed 
artery.  The  patient  falls  to  the  ground  unconscious  and  hemiplegic. 
If  the  hemiplegia  is  on  the  right  side  there  is  usually  aphasia.  The 
paralyzed  side  of  the  body  may  remain  quiet,  or  become  rigid,  or  be 
moved  involuntarily.  The  hemiplegia  and  unconsciousness  usually 
continue  up  to  death.  But  occasionally  we  see  a  patient  who  re- 
covers both  motion  and  consciousness. 

2.  The  dyspnoea  often  starts  with  an  ordinary  bronchitis.  The 
patients  cannot  lie  down,  they  suffer  from  the  constant  feeling  of 
dyspnoea,  the  pulse  is  full  and  tense,  the  drugs  which  usually  dilate 
the  arteries  are  of  little  or  no  effect,  the  scrotum  and  legs  become 
oedematous.     The  i^atients  live  only  a  few  weeks. 


CHRONIC  PRODUCTIYE  NEPHRITIS  WITHOUT  EXUDATION.  99 

3.  The  vomiting  may  at  first  resemble  that  of  an  acute  gastritis,  or 
that  caused  by  some  irritating  substance  in  the  stomach.  But  it  con- 
tinues, it  is  exhausting,  it  does  not  yield  to  the  ordinary  remedies 
directed  to  the  stomach ;  the  pulse  is  full  and  tense.  Such  vomiting, 
however,  can  often  be  stopped  by  the  drugs  which  dilate  the  arteries. 

4.  The  patients  after  an  injury,  or  a  surgical  operation,  or  without 
discoverable  cause  become  feeble,  the  heart's  action  is  feeble,  the 
urine  is  diminished  or  suppressed,  and  in  a  few  hours  the  patient  is 
dead.  These  cases  are  not  common.  They  are  very  disagreeable  for 
the  physician,  as  the  patients  seem  to  die  without  suflS.cient  cause^ 

Treatment. 

The  progress  of  the  nephritis  can  be  favorably  affected  by  atten- 
tion to  the  diet  and  mode  of  life,  and  to  climate.  As  regards  the  diet, 
the  quantity  of  sugars  and  starches  taken  should  be  restricted,  and 
the  ingestion  of  fats  encouraged.  The  use  of  wine,  spirits,  and  tobacco 
should  be  discontinued.  Exercise  in  the  open  air  is  to  be  advised 
as  long  as  the  strength  permits  of  it.  As  regards  climate,  we  must 
consult  the  idiosyncrasy  of  the  patient ;  it  should  be  a  climate  where 
he  eats  well,  sleeps  well,  and  feels  well.  There  is  a  decided  advantage 
in  not  remaining  in  the  same  place  throughout  the  year. 

In  the  patients  belonging  to  group  one,  with  urine  of  low  specific 
gravity  and  hypertrophy  of  the  left  ventricle,  it  will  be  found  that 
whenever  the  tension  of  the  pulse  is  increased  the  patients  do  not 
feel  quite  so  well.  When  this  is  the  case  potassium  iodide  will  often 
soften  the  pulse  and  remove  the  discomforts.  These  patients  can  also 
be  much  improved  by  regulated  exercise  in  the  open  air. 

In  the  patients  belonging  to  group  two  the  treatment  is  directed  to 
the  digestive  disturbances  and  the  nutrition.  The  regulation- of  the 
diet  and  the  mode  of  life,  lavage  of  the  stomach,  relieving  constipa- 
tion, and  increasing  the  jjroduction  of  bile  are  all  of  importance. 
When  the  jjroduction  of  urine  is  largely  in  excess  of  the  normal,  com- 
binations of  nux  vomica  and  sodium  bromide  will  sometimes  act  as  a 
specific  in  reducing  this  undue  quantity. 

In  the  patients  with  attacks  of  spasmodic  dyspnoea  much  can  be 
done  with  the  drugs  which  dilate  the  arteries  and  stimulate  the  heart. 
According  to  the  tension  of  the  pulse  and  the  strength  of  the  heart's 
action,  we  use  these  drugs  separately  or  together.  Chloral  hydrate, 
nitroglycerin,  and  potassium  iodide  are  the  most  reliable  of  the 
arterial  dilators;  digitalis,  strophanthus,  and  caffeine  are  the  best 
cardiac  stimulants  for  this  purpose. 

The  treatment  of  the  attacks  of  headache,  convulsions,  coma, 


100  DELAFIELD — DISEASES  OF  THE    KIDNEYS. 

hemiplegia,  and  vomiting  is  a  matter  of  importance.  Tlie  only  work- 
ing theory  that  one  can  go  on  is  to  believe  that  at  the  time  of  these 
attacks  there  is  an  irritant  poison  in  the  blood  which  causes  con- 
traction of  the  arteries,  and  that  the  cerebral  symptoms  are  due 
partly  to  the  contraction  of  the  arteries  and  partly  to  the  poison  it- 
seK.  What  the  poison  is  or  whether  it  is  in  all  cases  the  same  poi- 
son we  do  not  know. 

Evidently  the  indications  for  treatment  given  by  this  theory  are, 
first,  to  remove  the  poison  from  the  blood  and,  second,  to  dilate  the 
contracted  arteries. 

The  plans  which  are  ordinarily  used  to  remove  the  poison  from 
the  blood  are :  general  blood-letting,  purging,  sweating,  and  diuresis. 
These  measures  unquestionably  can  do  much  good.  "Whether  they 
do  so  because  they  remove  poison  from  the  blood,  or  because  they 
relieve  the  arterial  tension,  is  a  matter  open  for  discussion. 

Dilatation  of  the  arteries  can  be  effected  by  hypodermic  injections 
of  morphine;  by  nitroglycerin,  chloral  hydrate,  and  potassium 
iodide ;  and  by  sweating.  Very  often  with  these  remedies  the  pulse 
wiU  become  soft  and  the  cerebral  symptoms  will  disappear.  But 
after  the  nephritis  has  advanced  bej^ond  a  certain  point  it  is  found 
that  all  these  remedies  are  inert ;  the  tension  of  the  pulse  and  the  cere- 
bral symptoms  continue.  Or,  instead  of  this,  the  pulse  loses  its  ten- 
sion, becomes  rapid  and  feeble,  the  cerebral  symptoms  continue,  and 
the  patients  die. 

Puerperal  Eclampsia. 

During  the  later  months  of  pregnancy,  during  labor,  and  immedi- 
ately after  childbirth  women  not  infrequently  become  anaemic  and 
dropsical,  have  albumin  in  the  urine,  and  develop  alarming  cerebral 
symptoms — headache,  blindness,  convulsions,  and  coma. 

These  symptoms  are  especially  frequent  in  primiparae,  in  young 
women,  and  with  twin  pregnancies.  They  may  be  repeated  in  several 
successive  pregnancies.  They  belong  to  the  second  half  of  preg- 
nancy, increase  in  severity  as  the  pregnancy  advances,  and  are  at  their 
worst  during  labor. 

MoEBiD  Anatomy. 

In  women  dying  with   cerebral  symptoms  and  albuminuria   at 
about  the  time  of  childbirth  I  have  found  the  following  conditions : 
Normal  kidneys ; 
Dilatation  of  the  pelves  and  ureters ; 


PUERPERAL   ECLAMPSIA.  101 

Acute  degeneration  of  tlie  kidney ; 
Acute  exudative  nephritis ; 
Acute  productive  nephritis; 
Chronic  nephritis. 

In  some  of  the  patients,  even  in  young  women,  I  have  found  well- 
marked  disease  of  the  cerebral  arteries. 

Etiology, 

A  number  of  theories  have  been  entertained  as  to  the  causes  of 
puerperal  eclampsia.  It  must  be  confessed  that  none  of  them  is 
satisfactory,  and  that  the  subject  is  still  obscure.  The  most 'promi- 
nent explanations  are  as  follows : 

1.  Pressure  on  the  renal  veins  by  the  gravid  uterus  produces  a 
chronic  congestion  of  the  kidneys,  which  interferes  with  their  func- 
tions. 

2.  Pressure  of  the  uterus  on  the  ureters  renders  it  necessary  for 
the  kidneys  to  secrete  against  a  higher  pressure  so  that  they  are  un- 
able to  get  rid  of  the  proper  quantity  of  excrementitious  substances. 

3.  The  kidneys  are  obliged  to  excrete  waste  products  not  only 
from  the  mother,  but  also  from  the  enlarged  uterus  and  the  foetus,  and 
this  extra  work  they  are  unable  to  perform. 

4.  It  has  been  demonstrated  in  some  cases  that  before  the  convul- 
sions there  is  a  diminished  quantity  of  excrementitious  products  in 
the  urine,  and  after  the  cessation  of  the  con^oilsions  an  increase  of 
these  products ;  therefore  the  convulsions  are  due  to  the  retention  of 
these  excrementitious  substances  in  the  blood. 

5.  That  for  some  reason  the  patients  have  cerebro-spinal  conges- 
tion. 

6.  That  for  some  reason  they  have  cerebro-spinal  anaemia. 

7.  That  the  convulsions  are  of  the  nature  of  acute  epileptic  at- 
tacks due  to  irritation  of  nerves  in  the  pelvis. 

8.  That  the  enlarged  uterus  acts  as  an  irritant  to  the  vasomotor 
nerves  and  so  causes  a  contraction  of  the  arteries  throughout  the 
body. 

9.  That  the  enlarged  uterus  causes  irritation  of  the  vasomotor 
nerves  which  supply  the  renal  arteries ;  the  contraction  of  the  renal 
arteries  causes  death  or  degeneration  of  the  renal  epithelium;  the 
changes  in  the  renal  epithelium  render  the  kidneys  unable  to  excrete 
poisonous  substances;  the  accumulation  of  these  substances  in  the 
blood  causes  the  convulsions,  etc. 

10.  There  is  at  the  time  of  childbirth  in  some  women  a  toxic  sub- 
stance i)roduced  in  some  unknown  way,  which  is  not  caused  by  any 


102  DELATTET.T) — DISEASES  OF  THE  KIDNETS. 

change  in  the  function  of  the  kidneys,  but  which  is  capable  of  causing 
transudation  of  serum  from  the  vessels,  contraction  of  the  arteries, 
acute  degeneration  of  the  kidneys,  and  acute  nephritis.  In  other 
words,  the  changes  in  the  kidneys  are  not  the  cause  of  the  convul- 
sions, etc.,  but  they  are  the  result  of  the  same  poison  which  produces 
the  albuminuria  and  the  cerebral  symptoms. 

Symptoms. 

1.  There  is  a  considerable  number  of  pregnant  women  in  whose 
urine  during  the  latter  months  of  pregnancy  albumin  is  present  in 
appreciable  quantities;  they  have  no  other  symptoms  and  pass 
through  labor  without  trouble. 

2.  There  are  women  who,  during  the  latter  months  of  pregnancy, 
have  scanty  and  albuminous  urine,  more  or  less  dropsy  of  the  legs, 
and  become  pale  and  angemic.  They  may  pass  through  childbirth 
safely  and  do  well  afterward,  but  some  of  them  have  a  chronic  ne- 
phritis dating  from  the  pregnancy. 

3.  In  a  small  number  of  women  at  about  the  time  of  childbirth, 
either  before,  during,  or  after  labor,  there  are  cerebral  symptoms.  In 
some  of  these  women  albumin  has  been  present  in  the  urine  during 
the  pregnancy ;  in  others,  besides  the  albuminuria,  dropsy  and  anaemia 
have  also  been  present ;  but  in  others  the  cerebral  symptoms  are  sud- 
denly developed  without  any  premonitory  conditions. 

The  cerebral  attacks  are  characterized  by  nausea  and  vomiting, 
headache,  blindness,  muscular  twitchings,  general  convulsions,  stupor, 
coma,  hemiplegia,  a  rise  of  temperature,  a  pulse  of  high  tension, 
venous  congestion  of  the  skin ;  the  urine  is  diminished  in  quantity  or 
suppressed,  and  usually  contains  large  quantities  of  albumin.  The 
cases  vary  as  to  how  many  of  these  symptoms  are  present.  A  fair 
proportion  of  the  patients  survive  these  attacks,  although  the  children 
usually  die.  In  the  fatal  cases  death  takes  place  with  general  con- 
vulsions, with  hemiplegia,  or  with  coma. 

After  the  termination  of  the  labor  and  the  disappearance  of  the 
alarming  symptoms  the  anxieties  of  the  obstetrician  are  at  an  end, 
but  those  of  the  physician  begin.  For  in  many  of  these  women  a  ne- 
phritis originates  during  pregnancy,  which  continues  afterward  as 
a  chronic  inflammation  and  ultimately  destroys  life. 

Treatment, 

While  there  have  been  many  different  opinions  as  to  the  nature  of 
puerperal  eclampsia,  there  is  a  good  deal  of  uniformity  as  to  the  treat- 


SUPPURATIVE   NEPHRITIS.  103 

ment.  If  the  convulsions  come  on  at  about  tlie  end  of  pregnancy,  it 
is  generally  agreed  that  labor  should  be  brought  on  and  the  child  de- 
livered as  soon  as  possible.  Apart  from  this  we  try  to  unload  the 
veins  and  dilate  the  arteries.  This  can  be  done  by  general  blood- 
letting and  by  the  use  of  nitroglycerin,  chloral  hydrate,  and  opium. 
In  order  to  guard  against  the  cerebral  symptoms  it  is  of  more  practi- 
cal importance  to  watch  the  arteries  and  the  heart  than  to  test  the 
urine  for  albumin. 

Suppurative  Nephritis. 

Suppurative  inflammation  of  the  pelvis  of  the  kidney  and  of  the 
kidney  itself  occurs  under  several  different  conditions.  It  is  the  result 
of  injuries;  it  is  due  to  emboli;  it  occurs  without  discoverable  cause; 
it  is  secondary  to  cystitis,  the  cystitis  being  due  to  stricture  of  the 
urethra,  to  stone  in  the  bladder,  to  paraplegia,  to  operations  on  the 
urethra,  bladder,  and  uterus,  to  gonorrhoea,  or  to  enlarged  prostate. 
Chronic  suppurative  pyelo-nephritis  may  be  caused  by  the  presence 
of  calculi  in  the  pelvis  of  the  kidney. 

1.  Suppurative  Nephritis  from  Injury. 

Gunshot  wounds,  incised  or  punctured  wounds,  falls,  blows,  and 
kicks  are  the  ordinary  traumatic  causes.  If  the  injury  be  a  very  se- 
vere one,  it  causes  the  death  of  the  patient  in  a  short  time ;  if  it  be 
less  severe,  suppurative  inflammation  may  be  developed. 

The  inflammatory  process  may  be  diffuse,  so  that  the  whole  of  one 
or  both  kidneys  is  converted  into  a  soft  mass  composed  of  pus,  blood, 
and  broken-down  tissue;  or  it  is  circumscribed,  and  one  or  more 
abscesses  are  found  in  the  kidney,  which  may  communicate  with  its 
pelvis. 

Symptoms. — Rigors  mark  the  beginning  of  the  suppuration  and  are 
often  repeated  throughout  its  course.  A  febrile  movement  is  devel- 
oped, which  is  apt  to  assume  the  hectic  character  with  sweating. 
There  is  often  vomiting.  There  may  be  very  severe  pain  referred  to 
the  region  of  the  inflamed  kidney.  The  urine  is  diminished  or  sup- 
pressed ;  it  contains  blood  alone,  or  blood  and  pus.  In  the  bad  cases 
the  patients  pass  into  the  typhoid  state,  become  delirious,  and  die 
comatose,  or  with  a  rapid  and  feeble  pulse.  Or  the  disease  is  pro- 
tracted, the  patients  become  more  and  more  emaciated,  and  finally 
die  exhausted.  In  other  cases  the  symptoms  abate,  the  urine  returns 
to  its  natural  condition,  and  the  patients  recover. 

Treatment. — The   management  of  these  cases  is  rather  surgical 


104  DELAPIELD — DISEASES  OF  THE  KIDNEYS. 

than  medical.  The  external  wound  is  to  be  treated  antiseptically,  and 
tlie  suppurating  kidney  is  to  be  incised  or  removed,  as  may  be  nec- 
essary. 

2.  Abscesses  Peoduced  by  Emboli. 

In  ordinary  endocarditis  with  vegetations  on  the  valves  it  often 
happens  that  fragments  of  the  vegetations  become  fixed  in  the 
branches  of  the  renal  artery.  When  this  is  the  case  white  infarctions 
are  produced. 

With  malignant  endocarditis  and  with  septic  infections  emboli  find 
their  way  into  the  branches  of  the  renal  artery  and  set  up  circum- 
scribed foci  of  suppurative  inflammation.  The  kidneys  become  en- 
larged and  are  studded  with  little  white  points  surrounded  by  red 
zones.  These  little  white  points  are  formed  by  an  infiltration  of  pus 
cells  between  the  tubes,  followed  by  the  death  and  breaking  down  of 
the  kidney  tissue.  The  bacteria  of  suppuration  are  found  in  these 
little  abscesses. 

Symptoms. — These  embolic  abscesses  can  hardly  be  said  to  have  a 
clinical  history.  Whatever  symptoms  may  belong  to  them  are  lost  in 
those  of  the  general  disease  from  which  the  patient  is  suffering. 

3.  Idiopathic  Abscesses. 

These  occur  without  discoverable  cause.  Only  one  kidney  is  in- 
volved. We  find  after  death  part  of  the  kidney  destroyed ;  the  re- 
maining portions  contain  abscesses;  the  pelvis  is  dilated  and  con- 
tains pus,  the  capsules  are  thickened,  the  suppurative  inflammation 
may  extend  to  the  surrounding  tissues  so  that  sinuses  are  formed, 
and  even  perforations  into  the  intestine  or  through  the  diaphragm. 
It  is  very  difficult  in  these  cases  to  tell  whether  the  inflammation  be- 
gins in  the  kidney  or  in  its  pelvis. 

Symptoms. — The  symptoms  begin  gradually  and  are  for  some  time 
obscure.  There  are  repeated  chills  and  an  irregular  febrile  move- 
ment. The  patients  lose  flesh  and  strength,  become  ansemic,  and  are 
often  troubled  by  nausea  and  vomiting.  There  is  more  or  less  pain 
over  the  inflamed  kidney.  After  a  time  the  pelvis  of  the  kidney  may 
be  so  much  dilated  as  to  form  a  tumor.  If  the  pus  escapes  from  time 
to  time  through  the  ureter,  this  tumor  will  vary  in  size.  The  urine 
at  intervals  contains  pus  and  fragments  of  broken-down  kidney  tissue. 
If  the  suppuration  extends,  there  will  be  sinuses  running  behind  the 
peritoneum,  or  into  the  colon,  or  upward  through  the  diaphragm. 
The  disease  is  apt  to  last  a  long  time.  The  patients  are  liable  to  have 
chronic  nephritis  of  the  other  kidney,  or  waxy  degeneration  of  the 
viscera. 


SUPPURATIVE  NEPHRITIS.  105 

Treatment. — The  only  plan  of  treatment  is  to  cut  down  on  tlie  sup- 
purating kidney  and  treat  it  as  an  abscess,  or  to  remove  it  altogether. 

4.  Suppurative  Pyelonephritis  with  Cystitis. 

Both,  kidneys  become  inflamed.  The  pelves  are  congested  and 
coated  with  pus  or  fibrin.  The  kidneys  are  swollen,  congested,  and 
studded  with  foci  of  pus.  The  smallest  foci  are  not  visible  to  the 
naked  eye,  but  with  the  microscope  we  find  collections  of  pus  cells 
between  the  tubes,  with  swelling  and  degeneration  of  the  epithelium 
within  the  tubes.  The  larger  purulent  foci  look  like  white  streaks  or 
wedges  running  parallel  to  the  tubes  and  surrounded  by  zones  of 
congestion.  The  larger  abscesses  replace  considerable  portions  of 
the  kidneys. 

The  ureters  in  some  cases  are  inflamed,  their  walls  thickened, 
their  inner  surfaces  coated  with  pus  or  fibrin.  The  bladder  presents 
the  lesions  of  acute  or  of  chronic  cystitis. 

Etiology. — This  form  of  nephritis  seems  to  be  always  secondary 
to  a  cystitis,  the  infection  extending  from  the  bladder  through  the 
ureters  to  the  kidneys.  The  cases  of  cystitis  in  which  a  suppurative 
nephritis  is  likely  to  be  developed  are  those  due  to  strictures  of  the 
urethra,  stone  in  the  bladder,  operations  on  the  urethra,  bladder,  and 
uterus,  paraplegia,  gonorrhoea,  and  enlarged  prostate. 

Symptoms. — When  the  nephritis  occurs  with  cystitis  due  to  stone 
in  the  bladder,  strictures  of  the  urethra,  or  operations  on  the  genito- 
urinary tract,  the  symptoms  are  much  the  same.  The  patient  has 
first  the  symptoms  belonging  to  the  cystitis,  then  he  is  attacked  with 
chills  and  a  rise  of  temperature.  The  chills  are  repeated,  the  tempera- 
ture is  irregular  and  accompanied  by  profuse  sweating.  There  is  a 
rapid  change  in  the  general  condition  of  the  patient,  he  becomes  more 
prostrated  and  emaciated  from  day  to  day.  The  face  is  drawn  and 
anxious,  the  tongue  dry  and  brown,  the  pulse  rapid  and  feeble; 
delirium  is  developed  and  the  patient  finally  dies  in  the  septic  condi- 
tion. The  urine  is  diminished  in  quantity  or  suppressed ;  it  contains 
blood,  jjus,  and  mucus  derived  partly  from  the  bladder,  partly  from 
the  kidneys. 

Cases  of  suppurative  nephritis  due  to  a  gonorrhoeal  cystitis  are 
not  common,  but  several  of  them  have  been  observed.  Murchison 
describes  two  cases,  in  both  of  which  the  cerebral  symptoms  were 
very  marked — delirium,  convulsions,  and  coma.  I  have  seen  one  such 
case.  The  patient  was  a  prostitute  who  came  into  the  hospital  with 
a  si)ecific  vaginitis.  After  a  few  days  she  developed  the  symptoms  of 
an  acute  cyntitis;  then,  after  a  few  more  days,  slie  was  attacked  with 


106  DELAPIELD— DISEASES  OF  THE  Kn)ME,YS. 

chills  and  a  rise  of  temperature,  passed  rapidly  into  tlie  septic  condi- 
tion, and  died.  At  the  autopsy  there  were  found  acute  cystitis, 
pyelitis,  and  numerous  small  abscesses  in  both  kidneys. 

When  suppurative  nephritis  complicates  the  cystitis  due  to  en- 
larged prostate,  the  symptoms  are  somewhat  different.  The  patients 
are  usually  men  over  fifty  years  old.  They  have  generally  suffered 
from  the  symptoms  of  enlarged  prostate,  retention  of  urine  either 
constant  or  intermittent,  and  more  or  less  cystitis  with  pus  and  mucus 
in  the  urine.  Sometimes,  however,  no  such  history  is  obtained ;  the 
patients  assert  that  they  have  had  no  previous  bladder  trouble.  The 
first  symptom  is  a  diminution  in  the  quantity  of  urine,  with  the  ap- 
pearance of  blood  mixed  with  it,  or  the  urine  may  be  suppressed  alto- 
gether. The  blood  may  be  present  in  considerable  quantities  so  that 
the  patients  seem  to  pass  blood  instead  of  urine.  The  patients  rapidly 
become  prostrated  and  very  anxious.  There  are  usually  no  chills, 
and  there  may  be  no  rise  of  temperature.  The  prostration  becomes 
more  marked,  the  pulse  is  rapid  and  feeble,  the  skin  is  cold  and 
bathed  in  perspiration,  and  the  patients  die  in  collapse  at  the  end  of 
a  few  days.  Or,  instead  of  such  a  history,  the  patients  may  behave 
as  if  they  were  the  subjects  of  septic  poisoning. 

Prognosis. — Suppurative  nephritis  secondary  to  cystitis  is  a  very 
fatal  disease ;  so  far  as  I  know  all  the  patients  die. 

Treatment. — The  treatment  for  these  cases  is  altogether  a  preven- 
tive one  directed  to  the  cystitis.  When  the  nephritis  is  once  estab- 
lished we  have  no  further  control  over  the  case. 

Tubercular  Nephritis. 

The  different  portions  of  the  genito-urinary  tract — the  kidneys, 
ureters,  bladder,  seminal  vesicles,  prostate,  testicle,  uterus,  Fallopian 
tubes,  and  ovaries — may  become  the  seat  of  a  localized  tubercular 
inflammation. 

Such  an  inflammation  may  involve  one  of  these  organs,  or  several 
of  them.  If  several  of  them  are  involved,  they  are  on  the  same  side 
of  the  body,  usually  the  left  side.  The  inflammation  is  attended  with 
the  growth  of  tubercle  bacilli  and  the  formation  of  tubercle  tissue. 
The  tubercle  tissue  soon  dies  and  undergoes  cheesy  degeneration. 

In  the  kidneys  the  inflammation  begins  in  the  mucous  membrane 
of  the  pelvis  and  calyces  and  extends  to  the  parenchyma,  until  a  large 
part  of  the  kidney  is  replaced  by  the  degenerated  new  tissue.  The 
cheesy  masses  may  soften  or  become  calcified,  while  the  kidney  tis- 
sue between  them  is  converted  into  fibrous  tissue  more  or  less  infil- 
trated with  pus. 


NEW   GROWTHS   OP  THE   KIDNEY.  107 

The  other  kidney,  after  a  time,  is  apt  to  become  the  seat  of  the 
exudative  form  of  chronic  nephritis  with  waxy  degeneration  of  the 
blood-vessels. 

The  tubercular  nephritis  may  be  complicated  by  tubercular  inflam- 
mation of  other  parts  of  the  genito-urinary  tract  on  the  same  side  of 
the  body,  by  tubercular  peritonitis,  pulmonary  tuberculosis,  or  gen- 
eral tuberculosis. 

The  disease  is  said  to  occur  at  all  ages ;  it  is  most  frequent  in 
middle-aged  persons.     It  occurs  twice  as  often  in  men  as  in  women. 

Symptoms. 

The  urine  usually,  but  not  always,  contains  from  time  to  time 
blood,  pus,  detritus,  epithelium,  shreds  of  tissue,  and  tubercle  bacilli. 
When  the  other  kidney  has  become  the  seat  of  chronic  nephritis  the 
specific  gravity  of  the  urine  falls  and  albumin  and  casts  are  present. 

Pain,  either  continuous  or  in  paroxsyms,  and  tenderness  are  often 
present  in  the  inflamed  kidney.  There  may  be  hectic  fever  with 
night  sweats;  the  patients  gradually  lose  flesh  and  strength.  The 
kidney  may  be  enlarged  so  as  to  form  a  tumor  which  can  be  felt. 
After  a  time  there  are  added  the  symptoms  of  tubercular  inflamma- 
tion of  other  parts  of  the  genito-urinary  tract,  of  tubercular  perito- 
nitis, of  pulmonary  phthisis,  of  waxy  degeneration  of  the  viscera,  or 
of  chronic  nephritis  of  the  other  kidney. 

The  disease  lasts,  as  a  rule,  for  several  years.  Most  of  the  cases 
terminate  fatally,  but  it  is  possible  for  the  inflammation  to  stop  and 
for  the  patient  to  recover. 

Treatment. 

The  proper  treatment  for  tubercular  nephritis  is  the  removal  of 
the  diseased  kidney.  The  practical  difiiculty  is  to  make  the  diag- 
nosis before  other  parts  of  the  genito-urinary  tract  have  become  tuber- 
cular, or  before  the  remaining  kidney  has  become  the  seat  of  chronic 
nephritis. 

We  may  hope  that  climate  and  feeding  may  have  the  same  good 
effects  on  tubercular  nephritis  as  they  have  on  pulmonary  tubercu- 
losis. 

NeTV  Growths  of  the  Kidney. 

The  most  important  new  growths  of  the  kidney  are  those  which 
belong  to  the  classes  of  sarcoma  and  adenoma. 

Ttie  sarcomata  grow  from  the  kidney  itself,  or  from  its  pelvis. 


108  DELAFIELD— DISEASES   OF  THE  KIDNEYS. 

They  are  composed  of  connective  tissue  with  an  excess  of  cells,  witli 
whicli  may  be  mixed  mucous  tissue  or  muscular  tissue.  These 
tumors  often  reach  a  large  size  and  may  grow  for  a  number  of  years 
before  they  cause  death.  They  form  a  hard  abdominal  tumor  which 
at  first  retains  the  position  and  shape  of  the  kidney,  but  may  finally 
become  so  large  as  to  occupy  a  considerable  part  of  the  abdominal 
cavity. 

They  are  found  as  congenital  tumors,  are  rather  frequent  in  infants 
and  children,  and  are  occasionally  met  with  in  adults. 

The  adenomata  grow  in  the  cortex  of  the  kidney  in  the  form  of 
nodular  tumors.  They  may  follow  the  papillary  or  the  tubular  type. 
In  some  cases  the  tumor  or  tumors  never  attain  any  considerable  size, 
are  not  malignant,  and  give  rise  to  no  symptoms.  In  other  cases  the 
tumors  become  much  larger,  and  may  then  behave  like  malignant 
growths.  These  large  tumors  are  very  vascular.  The  adenomata 
which  run  a  malignant  course,  with  the  formation  of  metastatic 
tumors,  are  often  called  carcinomata. 

Symptoms. 

The  sarcomata  and  adenomata,  so  far  as  their  symptoms  are  con- 
cerned, may  conveniently  be  described  together.  In  both  of  them 
there  are  four  principal  symptoms :  a  tumor,  pain,  hsematuria,  and 
loss  of  nutrition. 

The  tumor  is  appreciable  as  soon  as  it  has  reached  a  sufficient 
size.  While  it  retains  the  natural  position  and  outlines  of  the  kidney 
the  diagnosis  is  comparatively  easj^,  but  as  the  tumor  becomes  larger 
and  adhesions  are  formed  it  becomes  more  difficult  to  distinguish  it 
from  other  abdominal  tumors. 

Hsematuria  is  jjresent  at  some  time  in  the  disease  in  about  half  the 
cases.  The  hemorrhages  may  be  very  large  with  rapid  anaemia  and 
exhaustion,  or  moderate  in  quantity,  or  so  little  as  only  to  be  appre- 
ciable with  the  microscope.  They  are  apt  to  recur  at  intervals  of  days 
or  weeks. 

The  pain  is  referred  to  the  situation  of  the  diseased  kidney.  It  is 
by  no  means  a  constant  symptom,  but  it  may  occur  early  and  be 
throughout  a  prominent  feature.  They  are  apt  to  come  on  in  attacks 
and  to  radiate  downward  along  the  course  of  the  ureter. 

Loss  of  appetite,  nausea  and  vomiting  are  troublesome  symptoms 
in  some  of  the  patients. 

The  loss  of  flesh  surely  comes  sooner  or  later,  but  it  is  curious  in 
some  cases  how  long  the  general  health  may  remain  unaffected,  and 
how  long  life  can  be  prolonged  even  with  enormous  tumors. 


bibliography.  109 

Treatment. 
The  same  rule  seems  to  hold  good  for  these  tumors  in  the  kidney 
as  for  the  same  tumors  in  other  parts  of  the  body.  If  the  kidney  be 
removed  while  the  growth  is  still  small,  the  prognosis  is  fairly  good. 
If  it  be  not  removed  until  the  tumor  is  large  or  until  metastatic 
tumors  have  been  formed,  the  prognosis  is  bad. 

Bibliography. 

Bright,  Richard  :  Practical  Observations  on  the  Nature  and  Symptoms  of  Dropsy 
in  All  its  Forms ;  in  which  a  new  and  more  correct  plan  of  treatment  is  proposed 
and  explained  ;  with  several  cases  illustrative  of  its  success.     London,  1839. 

Christison,  Robert :  On  Granular  Degeneration  of  the  Kidneys  and  its  Connexion 
with  Dropsy,  Inflammation,  and  Other  Diseases.     Edinburgh,  1839. 

Rayer,  Pierre  Franc^ois  Olive  :  Traite  des  Maladies  des  Reins  et  des  Alterations 
de  la  Secretion  urinaire,  etudiees  en  elles-mSmes  et  dans  leurs  rapports  avec  les 
maladies  des  uret^res,  de  la  vessie,  de  la  prostate,  de  I'ur^thre,  etc.    Paris,  1837-41. 

Frerichs,  F.  T.  :  Die  Bright'sche  Nierenkrankheit  und  deren  Babandlung. 
Braunschweig,  1851. 

Johnson,  George  :  Lectures  on  Bright's  Disease.     London,  1874. 

Traube,  L.  :  Ueber  den  Zusammenhang  von  Herz-  und  Nierenkrankheiten. 
Berlin,  1856. 

Gesammelte  Beitrage  zur  Pathologic  und  Physiologic.  Berlin,  1871-78. 

Stewart,  T.  Grainger  :  A  Practical  Treatise  on  Bright's  Disease  of  the  Kidneys. 
3d  ed.     New  York,  1871. 

Dickinson,  William  Howship  :  On  the  Pathology  and  Treatment  of  Albuminuria. 
New  York,  1868. 

Diseases  of  the  Kidneys  and  Urinary  Derangements.  Part  3.  Lon- 
don, 1877. 

Bartels,  Carl :  Klinische  Studien  ilber  die  verschiedenen  Formen  von  chronischen 
diffusen  Nierenentzlindungen.     Sammlung  klinischer  Vortrage,  No.  25,  1871. 

— — Structural  Diseases  of  the  Kidney  and  the   General    Symptoms   of 

Renal  Affections,  in  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine,  vol.  xv. 
New  York,  1877. 

Cornil,  Andre  Victor  :  Sur  les  Lesions  anatomiques  du  Rein  dans  1' Albuminuric. 
Paris,  1867. 

Cornil  and  Brault :  Etudes  sur  la  Pathologie  du  Rein.    Paris,  1884. 

Gull  and  Sutton  :  Medico-Chirurgical  Transactions,  1872. 

Cohnheim,  Julius  :  Yorlesungen  uber  allgemeine  Pathologie.     Berlin,  1877-80. 

Charcot,  J.  M.  :  Le9ons  sur  les  Maladies  du  Poie  et  des  Reins.    Paris,  1882. 

Langhans,  Theodor :  Virchow's  Archiv,  Bd.  Ixxvi.,  1879. 

Rosenstein,  Siegmund :  Pathologie  und  Therapie  der  Nierenkrankheiten. 
Berlin,  1886. 

Friedlander,  Carl :  Fortschritte  der  Medicin,  No.  3,  1883. 

Leyden,  E.  :  Zeitschrif  t  f  ilr  klinische  Medicin,  xi. ,  1886. 

Virchow,  Rudolph:  Virchow's  Archiv,  Bd.  iv.,  1852. 

Klebs,  E.  :  Handbuch  der  pathologischen  Anatomic.     Berlin,  1878-80. 

Rokitansky,  Carl :  Lehrbuch  der  pathologischen  Anatomic.     Wien,  1855-61. 

Rindfleiscli,  G.  E.  :  Lehrbuch  der  pathologischen  Gewcbelehre.     Leipzig,  1876. 

Zieglcr,  Ernst :  Lehrbuch  der  allgemeinea  pathologischen  Anatomic  und  Patho- 
genese.     Jena,  1890. 


DISEASES  OF  THE  KIDNEYS 

(SURGICAL) 

AND  OF  THE  URETERS. 


BY 

REGINALD  HARRISON, 

LONDON. 


DISEASES    OF   THE    KIDNEYS   (SURGI- 
CAL) AND  OF  THE  URETERS. 


SURGICAL  DISORDERS  OF  THE   KIDNEYS. 

During  recent  years  a  considerable  number  of  diseases  involving 
the  kidney  and  its  main  duct  bave  been  brought  within  the  reach  of 
surgery,  and  no  treatise,  for  the  use  of  practitioners,  relating  to  the 
disorders  of  this  organ  can  have  any  claim  to  completeness  which 
does  not  include  this  aspect  of  the  subject.  Medicine  and  surgery 
may  here  find  a  common  ground  where  it  is  not  always  easy  to  define 
the  respective  domains  of  the  physician  and  surgeon. 

It  will  be  my  object  to  give  a  concise  account  of  the  surgery  of 
these  parts,  as  well  as  to  describe  the  various  proceedings  of  a  more 
or  less  mechanical  nature  which  are  now  recognized  as  applicable  to 
either  their  cure  or  their  relief.  The  affections  to  be  considered  in- 
clude : 

Injuries  of  the  kidney. 

Undue  mobility  of  the  kidney. 

Perinephritic  and  nephritic  suppurations. 

Surgical  kidney. 

Kenal  fistula. 

Hydro-  and  pyo-nephrosis. 

Kenal  calculus. 

Tubercular  kidney. 

Deformities  and  mal-positions  of  the  kidney. 

Hydatids  of  the  kidney. 

Tumors  of  the  kidney. 

To  the  diseases  of  the  pelves  and  of  the  ureters,  as  far  as  it  is  pos- 
sible, a  separate  section  will  be  devoted. 

Injuries  of  the  Kidney. 

Protected  as  they  are,  partly  by  bony  walls,  and  more  extensively 
by  the  muscles  and  fasci&e  constituting  the  abdominal  parietes,  le- 
sions of  these  organs  are  comparatively  rare  when  we  consider  the 

Vol..   L— 8 


114  HABEISON — DISEASES  OE  THE  KIDNEYS  AND  UEETEES. 

frequency  with  whicli  the  trunk  is  exposed  to  injuries  of  all  kinds. 
Botk  civil  and  military  practice  will,  however,  be  found  to  furnish, 
numerous  instances  and  many  varieties  requiring  some  classification. 

Breaches  of  surface  involving  the  kidney  may  be  divided  into  two 
classes,  namely,  punctured  wounds  such  as  are  inflicted  by  the  use  of 
sharp  instruments  as  by  stabbing,  and  contusions  and  lacerations 
which  for  the  most  i)art  are  occasioned  by  the  application  to  the  body 
of  other  forces,  and  are  usually  unattended  with  a  lesion  of  the  integ- 
uments. 

Some  rare  cases  are  recorded  of  hernia  of  the  kidney  through  a 
wound  in  the  abdominal  wall,  of  which  the  following  quoted  by 
Pilcher  (from  a  repoi*t  in  the  Wiener  medicinische  Wochensclirift, 
1873)  may  be  taken  as  a  typical  example : 

Case. — "June  3d,  1873,  S.  P.,  aged  25,  was  stabbed  with  a  knife 
in  the  left  hypochondrium ;  two  or  three  hours  after  a  cough  set  in, 
which  caused  the  kidney  to  jjrotrude  through  the  wound.  At  the  end 
of  twenty-four  hours  he  jDresented  himself  at  the  clinic  of  Professor 
Brandt,  in  Klausenburg,  having  a  pulse  of  80,  a  temperature  nearly 
normal,  and  being  able  to  walk  to  a  gallery  to  be  photographed.  On 
the  fourth  day  after  being  wounded  the  kidney  was  drawn  out  and 
severed,  after  its  pedicle  had  been  ligatured.  Bapid  recovery  re- 
sulted. At  no  time  did  he  show  symptoms  of  uraemia  or  peritonitis. 
The  quantity  of  urine  secreted  increased  daily  while  he  was  under 
observation.     June  23d  he  left  the  hospital,  able  to  work  as  before." 

Cases  of  punctured  or  incised  wounds,  for  instance  in  the  loins  in 
the  direction  of  the  kidney  as  determined  by  examination  either  with 
the  finger  or  a  probe,  and  attended  with  more  or  less  hsematuria  and 
escape  of  urine  by  the  wound,  require  treatment  on  general  surgical 
principles.  If  the  bleeding  is  considerable,  as  evidenced  by  what 
escapes  externally  or  by  the  urine  passed  through  the  urethra,  the 
wound  should  be  opened  up  and  explored  to  the  bottom  and  the  con- 
dition of  the  kidney  ascertained.  Where  the  injury  does  not  go  be- 
yond the  kidney  hemorrhage  may  as  a  rule  be  arrested  hj  packing 
the  wound  with  antiseptic  gauze  around  a  drainage  tube  and  the  ap- 
plication of  a  wood-wool  compress.  When  the  kidney  is  wounded, 
for  instance,  by  a  bayonet  thrust  as  a  soldier  is  retreating,  the  organ 
may  be  transfixed  and  the  peritoneal  cavity  opened  and  filled  with 
blood.  If  there  is  reason  to  believe,  either  from  digital  exploration 
or  from  the  condition  presented  by  the  abdomen,  apart  from  the 
question  of  hemorrhage,  that  this  space  is  invaded,  a  laparotom7 
should  be  proceeded  with  in  preference  to,  or  even  in  addition  to,  the 
enlargement  of  the  original  wound,  as  it  is  not  unlikely  that  a  perfora- 
tion of  the  intestine  may  have  also  been  occasioned.  Such  a  com- 
plicated lesion  as  this,  would  necessarily  require  the  removal  of  the 


INJURIES  OP  THE  KIDNEt.  115 

kidney  in  addition  to  the  closure  by  suture  of  tlie  intestinal  wound. 
It  must  not  be  forgotten  that  a  stab  wound  of  tbe  kidney  is  not,  as  a 
rule,  a  fatal  injury  or  one  tliat  requires  the  removal  of  the  organ; 
whereas,  if  complicated  with  a  penetration  of  the  intestinal  viscera, 
there  is  little  chance  of  recovery  unless  the  latter  lesion  can  be  .ex- 
posed and  sutured.  I  once  saw  the  back  of  the  colon  punctured  in 
the  course  of  an  operation  for  exploring  the  right  kidney.  The  wound, 
being  a  very  small  one,  was  included  in  a  noose  of  catgut  ligature,  and 
the  patient  made  a  good  recovery.  A  stone  was  found  in  the  cortex 
of  the  kidney  and  removed. 

Nor  are  the  principles  of  treatment  in  the  case  of  gunshot  wounds 
of  the  abdominal  parietes  involving  a  kidney  materially  different  from 
those  just  referred  to.  The  wounds  are  usually  associated  with  more 
or  less  damage  to  surrounding  parts  such  as  the  liver,  diaphragm,  and 
intestines,  and  are  as  a  rule  speedily  fatal.  Taking  some  of  those  in- 
stances of  perforation  of  the  kidney  by  non-explosive  bullets  where 
death  appears  to  have  resulted  from  the  escape  of  urine  into  the 
peritoneal  cavity,  rather  than  from  any  other  effects  of  the  injury, 
a  laparotomy  with  removal  of  the  kidney  would  seem  to  be  the  only 
expedient  at  all  likely  to  be  successful.  Some  years  ago,  before  ab- 
dominal surgery  was  developed,  I  remember  seeing  a  youth  who  had 
been  shot  in  the  back  accidentally  by  a  playmate  with  a  small  pistol 
bullet  not  much  larger  than  a  pea.  He  died  in  the  course  of  three 
days  from  peritonitis.  An  autopsy  showed  that  the  projectile  had 
perforated  the  kidney  and  was  lying  loose  in  the  peritoneal  cavity. 
Death,  I  believe,  was  caused  by  the  flow  of  urine  and  blood  into  the 
abdomen,  and  in  the  present  day  would  have  been  averted  by  a  lapa- 
rotomy. The  difficulties,  however,  arising  out  of  the  circumstances 
under  which  lesions  of  the  kidney  of  this  grave  character  are  attended 
will  frequently  be  found  insuperable,  but  here  and  there  a  case  will 
occur  where  life  may  be  saved  by  prompt  surgical  interference.  Care- 
ful and  judicious  exploration  of  the  wound  in  cases  of  doubt  and 
danger  is,  however,  to  be  commended. 

For  the  less  complicated  wounds  involving  the  kidney,  both  gun- 
shot and  incised,  it  does  not  appear  that  there  is  much  risk  arising 
out  of  the  extravasation  of  urine  into  the  cellular  tissue  around  the 
organ,  so  far  as  is  gathered  from  such  experience  as  the  American  war 
afforded.  Little  else  than  good  drainage,  the  removal  of  foreign 
debris,  and  some  simple  dressing,  in  the  absence  of  complications, 
is  required. 

Passing  to  those  varieties  of  kidney  lesion  which  are  more  fre- 
quently met  with  in  civil  i)ractice,  it  will  be  noted  that  they  usually 
happen  without  any  breach  of  surface  or  even  evidence  of  local  cour 


116  HAERISON — DISEASES  OF  THE  KIDNEYS  AND  URETERS. 

tusion.  The  history  of  some  of  these  cases  and  the  circumstances 
attending  them  are  often  at  first  clouded  by  the  insensibility  of 
alcohol,  and  death  is  known  to  have  occurred  from  a  lesion  which 
was  never  diagnosed,  for  the  reason  that  nothing  obvious  was  present 
to^aise  such  suspicion. 

Contused  wounds  of  the  kidney  are  for  the  most  part  occasioned  by 
the  application  of  considerable  violence  in  the  direction  of  the  loins, 
as  in  falls  from  a  height,  crushes  and  squeezes  as  by  carriage  wheels, 
and  the  like.  It  sometimes  happens  that  very  severe  lacerations  of 
the  kidney  may  be  inflicted  without  any  sufficient  indication  of  the 
lesion  being  apparent  for  some  time  afterward,  and  the  attention  of 
the  surgeon  is  not  directed  to  what  has  actually  occurred,  until  some 
of  the  secondary  effects  of  extravasation  of  urine,  inflammation,  or 
hemorrhage  appear  upon  the  scene.  Mr.  Henry  Morris,  to  whom 
we  are  so  largely  indebted  for  developing  the  surgery  of  the  kidney, 
records'  a  case  of  this  kind  "  where  the  patient  was  unable  to  give  any 
explanation  of  the  onset  of  his  illness  and  denied  any  recollection  of 
having  had  an  injury,  but  it  is  probable  that  while  intoxicated  he 
met  with  an  injury  to  his  side."  After  a  somewhat  vague  illness  of 
five  weeks'  duration  Mr.  Morris  saw  the  patient  in  consultation,  and 
diagnosing  kidney  trouble  made  an  exploratory  incision  in  the  left 
ilio-costal  region.  A  very  large  amount  of  blood  clot  was  discovered 
in  the  retroperitoneal  space,  when  it  was  ascertained  that  the  source 
of  the  hemorrhage  was  a  deep  rent  on  the  anterior  surface  of  the 
kidney.  As  it  was  probable  that  fresh  bleeding  would  occur,  the 
kidney  was  removed,  and  the  patient  made  a  good  recovery. 

Pathologically  speaking,  kidney  lesions  present  every  variety  in 
degree,  from  very  small  abrasions  of  the  cortical  substance  accom- 
panied by  slight  and  transient  hfematuria  to  the  tearing  of  the  organ 
almost  completely  across.  One  or  two  illustrations,  as  indicating 
points  in  diagnosis  and  treatment,  may  be  given. 

Case. — A  dock  laborer,  aged  42,  was  in  the  summer  of  1865  ad- 
mitted into  the  Liverpool  Northern  Hospital  under  my  care,  for  an 
injury  to  his  back,  caused  by  falling  down  the  hold  of  a  steamship  on 
to  the  edge  of  a  case  of  goods.  The  patient  was  much  collapsed,  and 
there  was  a  contusion  in  the  right  lumbar  region,  without  any  breach 
of  surface.  On  partially  recovering  from  his  collapse,  in  the  course  of 
a  few  hours,  he  passed  urine  deeply  discolored  by  blood  and  small 
clots.  On  the  day  following  the  injury  the  urine  contained  some 
long  worm-like  clots  which  had  been  moulded  within  the  ureter. 
These  were  not  present  after  the  third  day.  In  addition,  by  the 
microscope,  blood-casts  of  the  uriniferous  tubes  were  occasionally 
seen.  The  patient's  condition  gradually  improved,  though  the  urine 
showed  traces  of  blood  for  nearly  three  weeks. 


mjURIES  OF  THE  KIDNEY.  117 

In  injuries  involving  a  lesion  of  an  internal  organ  we  recognize  in 
the  collapse  that  follows  a  provision  for  favoring  the  process  of  clot- 
ting by  which  the  vessels  are  sealed  and  excretion  is  suspended.  The 
latter  is  important,  for  if  the  laceration  were  sufficient  to  permit  of 
urine  escaping  into  the  tissues  about  the  kidney,  damage  would  be 
done,  such  as  is  seen  when  this  secretion  is  elsewhere  extravasated. 
For  some  time  afterward  the  injured  kidney  must  be  little  else  than 
a  percolator  of  water,  minus  the  urinary  salts,  the  excretion  of  the 
latter  being  provided  for  by  a  compensating  action  on  the  part  of  the 
opposite  organ.  It  is  to  the  immediate  plugging  of  the  renal  blood- 
vessels, coupled  with  the  fact  that,  if  time  is  allowed,  the  uninjured 
organ  is  capable  of  doing  double  duty,  that  so  many  recoveries  take 
place  after  rupture  of  the  kidney.  Hence  we  prefer  to  meet  the  col- 
lapse attending  this  injury  by  warmth,  in  the  shape  of  hot  blankets 
and  sinapisms,  which  by  determining  blood  to  the  skin  favors  repair. 
The  bleeding  from  a  lacerated  kidney  usually  subsides  spontaneously, 
•but  when  considerable  its  arrest  may  be  aided  by  gallic  acid,  matico, 
or  ergot. 

Dr.  H.  G.  Rawdon  reports  a  case  ^  which  I  had  the  advantage  of 
seeing  with  him,  and  which,  in  connection  with  the  treatment  of  ex- 
tensive ruptures  of  the  kidney,  was,  at  the  time  of  its  occurrence, 
unique. 

Case, — A  boy  aged  12  years  was  admitted  into  the  Liverpool 
Children's  Hospital  on  Dec.  7th,  1882,  having  the  day  previously 
fallen  out  of  a  window  a  distance  of  eight  feet.  On  admission  he  was 
suffering  from  pain  in  the  side  and  there  was  blood  in  the  urine. 
The  hsematuria  continued  and  there  was  much  difficulty  in  urination 
from  blood-clots.  As  these  symptoms  continued  and  cystitis  super- 
vened, on  the  seventeenth  day  after  the  injury  the  right  kidney  was 
cut  down  upon  and  found  imbedded  in  a  mass  of  clots.  On  these  being 
cleared  away  the  organ  was  found  almost  divided  into  two  equal  por- 
tions by  a  transverse  laceration.  The  torn  portions  were  ligatured 
and  removed  by  scissors.  The  operation  was  followed  by  considerable 
relief  and  urine  was  freely  secreted.  The  cystitis,  however,  did  not 
abate,  and  as  the  bladder  appeared  to  be  blocked  with  blood  clots, 
lateral  cystotomy  was  performed  four  days  after  the  nephrectomy, 
which  permitted  the  removal  of  a  coagulum  about  the  size  of  a  wal- 
nut. Two  days  after  this  it  is  reported  that  a  large  irregular-shaped 
clot,  partially  disorganized  and  foetid,  was  passed  by  the  wound.  The 
patient,  however,  gradually  sank  and  died  twenty-four  days  after 
the  nephrectomy.  At  the  autopsy  the  opposite  kidney  was  found 
enlarged,  and  on  section  showed  numerous  points  of  suppuration. 
Both  the  pelvis  of  the  kidney  and  corresponding  ureter  were  con- 
siderably dilated  and  filled  with  pus.  The  condition  of  the  re- 
maining kidney  undoubtedly  caused  the  death  of  the  patient.  It 
was  also   equally   clear  that  the   state    of    the   bladder  was    alone 


118  HAEEISON— DISEASES   OF  THE  KIDNEYS  AND  UEETEKS. 

responsible   for  tlie  suppurative  nephro-pyelitis  wliicli  had  ensued 
and  caused  death. 

Though  it  is  easy  to  be  wise  after  an  event,  this  instructive  and  im- 
portant case  indicates  that,  had  nephrectomy  been  earlier  performed, 
the  hemorrhage  and  clotting  within  the  bladder  would  have  been  pre- 
vented. In  the  latter  was  to  be  found  the  cause  of  the  cystitis  and 
urinary  obstruction  which  eventually  caused  the  destruction  of  the 
remaining  kidney  by  disseminated  suppuration. 

Wounds  of  the  kidney,  as,  for  instance,  those  inflicted  for  surgical 
purposes,  are  occasionally,  though  rarely,  followed  by  acute  symp- 
toms of  septic  poisoning  of  an  exceptional  nature.  Mr.  Dobson '  has 
recorded  a  typical  example  which  I  will  quote. 

Case. — "  The  case  was  that  of  a  married  woman,  aged  35,  who  had 
for  some  time  been  treated  for  painful  bladder  troubles ;  she  was  ad- 
mitted into  hospital,  with  a  swelling  in  the  left  loin,  connected  with 
the  kidney  and  probably  due  to  pus.  I  incised  the  kidney  with  anti- 
septic precautions,  letting  out  pus  which  was  in  the  pelvis,  and  aftei* 
examining  the  interior  of  the  organ  with  my  finger,  inserted  a  drain- 
age tube.  The  operation  took  place  at  1 :  30  p.m.  and  occupied  only 
a  few  minutes ;  at  4 :  30  she  was  taken  with  a  violent  rigor,  and  at  5 
o'clock  her  temperature  was  106.4°.  A  dose  of  15  grains  of  quinine 
was  administered,  and  her  temperature  fell  to  105°  at  6:30;  104°  at 
7 :  30 ;  103°  at  8 :  30 ;  rose  to  104°  at  10 :  30,  and  fell  again  to  103.2°  at 
12  P.M.  She  died  at  5  a.m.,  about  sixteen  hours  after  the  operation. 
There  was  neither  loss  of  blood  nor  shock.  The  external  wound, 
which  was  small,  was  dressed  antiseptically . " 

The  case  is  not  only  of  importance  as  a  record,  but  as  showing 
that  the  phenomena  of  urethral  fever  are  not  limited  to  lesions  of  the 
male  urinary  passage. 

Movable  Kidney. 

A  kidney  which  is  unduly  movable  either  by  reason  of  the  pres- 
ence of  a  mesonephron  permitting  it  to  float,  or  in  consequence  of  the 
loosening  of  its  natural  attachments  to  the  abdominal  parietes  by 
whatever  means  it  may  be  caused,  is  often  a  considerable  source  of 
discomfort  to  the  individual.  Without  discussing  the  pathology  of 
the  subject  and  the  varieties  it  presents,  I  would  lay  stress  on  the  fre- 
quency with  which  the  painful  form  of  the  disorder  is  traceable  to  a 
previous  injury. 

Instances  often  come  under  observation  of  persons  suffering  from 
it  as  a  result  of  violent  concussions  to  which  the  body  has  been  sub- 
jected. Hence  the  importance  of  rest  and  support  in  all  cases  where 
injuries  of  this  kind  have  been  sustained.     I  had  a  gentleman  under 


MOVAELE   KIDNEY.  119 

observation  who  suffered  much  inconvenience  from  a  movable  kidney, 
which  was  not  complained  of  before  he  had  a  severe  fall  from  his 
horse.  Mr.  Bruce  Clarke  ^  has  drawn  attention  to  the  resemblance 
between  what  he  describes  as  acute  renal  dislocation  and  the  parox- 
ysms of  renal  colic. 

A  kidney  which  moves  about  from  whatever  cause  sometimes  pro- 
vokes symptoms  of  much  distress  to  the  patient— symptoms  which, 
though  often  attributed  to  dyspepsia,  have  this  peculiarity  that  no 
medicine  for  indigestion  and  the  like  disorders  ever  alleviates  them. 
There  is  pain  and  abdominal  dragging  and  sensations  of  a  most  per- 
sistent character. 

In  many  instances  a  kidney  that  moves  unduly  may  be  recognized 
by  abdominal  manipulation.  A  tumor  can  be  felt  and  rolled  about 
in  various  directions.  The  absence  of  this  sign,  however,  cannot  be 
accepted  as  indicating  that  no  such  abnormality  exists.  In  a  stout 
woman  upon  whom  I  operated  for  symptoms  which  pointed  to  a  mov- 
able kidney  and  where,  in  the  absence  of  relief  by  abdominal  belts 
and  dyspeptic  medicine,  I  made  an  exploration,  on  removing  the 
perirenal  fat  I  could  move  the  kidney  in  almost  any  direction  by 
the  tip  of  my  index  finger.  I  fixed  the  kidney  with  sutures  and  the 
patient  completely  recovered  and  after  the  lapse  of  seven  year's  is 
in  excellent  health.  Hence  in  the  diagnosis  of  movable  kidney  we 
must  to  a  certain  extent  be  dependent  upon  symptoms  and  the  ex- 
ploratory proceedings  which  the  continuation  of  these  signs  sometimes 
undoubtedly  indicates.  Where  there  are  symptoms  of  a  constant 
nature  which  threaten  to  injure  the  health  of  the  patient,  and  in  the 
absence  of  any  relief  from  an  abdominal  belt  or  support,  the  ques- 
tion of  operation  will  have  to  be  entertained. 

Nephrorrhaphy,  or  the  fixation  of  a  kidney  by  suture,  is  a  proceed- 
ing which  may  be  practised  with  very  good  result.  It  consists  in  ex- 
posing the  kidney  by  an  incision  from  the  loin  and  then  securing  it 
by  means  of  strong  catgut  sutures  passed  within  the  fibrous  capsule 
and  out  through  the  edges  of  the  parietal  wound.  It  may  be  urged 
that  this  is  not  possible  in  the  case  of  kidneys  which  are  rendered 
movable  by  reason  of  a  complete  mesonephron,  and  that  where  there 
are  grounds  for  the  belief,  from  the  obvious  mobility  of  the  organ, 
that  this  is  the  case  a  laparotomy  should  be  proceeded  with  and  the 
organ  removed  in  this  way.  I  cannot,  however,  indorse  a  practice 
of  this  kind  until  the  simpler  proceeding  has  first  been  tried  and 
exploration  effected  from  the  loin.  Though  I  have  operated  several 
times  for  a  movable  kidney  and  have,  on  more  than  one  occasion, 
met  with  what  appeared  to  be  a  fairly  constituted  mesonephron,  I 
never   experienced   much  difficulty  in   reaching  the  surface   of  the 


120  HAERISOiSr — DISEASES  OF  THE   KIDNEYS  AND  URETERS. 

kidney.  Failing  in  a  proceeding  of  this  kind,  and  the  pressing  symp- 
toms continuing  after  the  healing  of  the  lumbar  incision,  I  should 
have  no  hesitation  in  resorting  to  a  laparotomy  and  removing  the 
organ  entirely.  Nephrectomy  should,  however,  not  be  adopted  with- 
out the  most  careful  consideration,  as  the  liability  to  kidney  disease 
as  well  as  its  gravity,  so  far  as  the  remaining  organ  is  concerned, 
is,  as  might  be  expected,  considerably  increased. 

Perinephritic  and  Nephritic  Suppurations. 

I  will  now  pass  on  to  notice  the  suppurative  effects  of  inflamma- 
tion as  observed  around  and  within  the  kidney  requiring  surgical  at- 
tention. Situated  as  these  organs  are,  the  consequences  of  a  lesion 
from  without,  as  a  blow  on  the  loins,  or  the  irritation  proceeding 
from  within,  as  by  the  presence  of  a  renal  stone  or  tubercle,  may  be 
to  excite  suppurative  inflammation  in  the  fat  and  cellular  tissue  in 
which  they  are  more  or  less  loosely  embedded.  This  condition  is 
known  by  the  term  of  perinephritis. 

When  we  consider  how  deeply  the  mischief  is  in  the  first  instance 
situated,  and  the  nature  of  the  texture  in  which  it  is  located,  it  is  easy 
to  appreciate  the  difficulty  of  making  an  early  and  correct  diagnosis, 
and  to  understand  how  readily,  before  the  superficial  tissues  are 
implicated,  the  products  of  inflammation  may  travel  to  and  involve 
neighboring  parts.  When  suppuration  has  occurred,  as  is  usually 
the  case,  numerous  instances  are  recorded  showing  how  the  pus, 
when  left  to  its  own  direction,  has  found  its  way  into  the  corre- 
sponding kidney  or  into  the  adjacent  spaces  of  the  thorax  and  ab- 
domen or  their  respective  viscera.  Hence  a  severe  blow  over  the 
loin,  or  the  sudden  movement  of  a  calculus  within  the  kidney,  are 
conditions  which  are  not  to  be  looked  upon  too  lightly,  especially 
when  either  happens  in  persons  who  are  to  be  regarded  as  cachectic, 
or  in  poor  physical  condition. 

Though  most  frequently  caused  by  direct  violence  applied  over 
the  loin,  or  by  disorders  of  the  urinary  tract  which  render  all  parts  of 
the  apparatus  susceptible  to  inflammation,  perinephritis  is  some- 
times produced  by  inflammatory  extensions  from  such  other  parts  as 
the  liver,  gall-bladder,  spleen,  caecum,  and  vertebrae.  It  is  in  tissue 
like  the  subperitoneal  that  inflammatory  burrowing  may  occur  with 
considerable  facility. 

Perinephritis  is  characterized  by  the  local  and  general  symptoms 
of  inflammation:  there  is  usually  some  swelling  in  the  loin  as  com- 
pared with  the  opposite  one ;  tenderness  on  pressure  may  be  discov- 
ered if  sought  for,  and  the  actual  occurrence  of  suppuration,  or  the 


PEKINEPHRITIC  AND  NEPHRITIC  SUPPURATIONS.  l2l 

presence  of  pus  around  the  kidney,  leads  to  tliose  variations  in  the 
temperature  as  shown  by  the  thermometer,  which  the  surgeon  is  not 
at  all  likely  to  disregard.  Very  little  reliance  can  be  placed  on  the 
discovery  of  fluctuation  as  an  indication  that  pus  is  present,  perhaps 
two  or  even  three  inches  from  the  surface.  Long  before  this  is  de- 
monstrable to  the  touch  the  practical  surgeon  will  have  reached  it 
by  an  exploratory  incision  in  the  loin  under  an  anaesthetic,  in  the 
course  of  which  many  ounces  of  matter  may  escape.  To  wait  until 
fluctuation  can  be  made  out  is  often  to  allow  valuable  time  to  elapse 
in  which  serious  if  not  fatal  mischief  may  be  done.  Mr.  Morris 
refers  to  an  inability  to  extend  the  thigh  of  the  affected  side  as  in  his 
experience  an  early  sign  of  mischief.  The  matter  evacuated  in  ab- 
scesses of  this  kind  is  variable  in  character;  in  some  it  is  thin  and 
ichorous,  in  others  laudable,  while  occasionally  it  is  most  offensive 
with  a  decidedly  fsecal  odor. 

In  the  treatment  of  this  affection,  though  sedative  applications  to 
the  part  in  the  way  of  fomentations  and  poultices  of  flax-seed  often 
afford  great  relief  in  the  early  stage,  the  surgeon  should  not  be 
tempted  to  unduly  postpone  the  search  for  and  evacuation  of  matter. 
When  the  part  becomes  tense  and  hard,  and  the  swelling  and  uneasy 
sensations  of  the  patient  are  not  subsiding,  the  presence  of  pus 
should  be  ascertained  either  by  means  of  the  aspirator  or  by  an  ex- 
ploratory incision  in  the  loin.  The  opening,  as  a  rule,  should  be 
sufficiently  free  to  enable  the  abscess  to  empty  itself  easily  without 
the  use  necessarily  of  a  drainage-tube,  though  the  latter  need  not 
be  dispensed  with.  As  the  abscess  contracts  the  drainage-tube  may 
be  gradually  shortened,  but  this  process  should  not  be  unduly  hur- 
ried, otherwise  a  troublesome  sinus  may  be  the  result.  It  is  hardly 
necessary  to  remark  that  all  antiseptic  precautions  are  to  be  taken. 

Nephritis,  resulting  in  abscess  of  the  kidney  independent  of  gen- 
eral septic  conditions,  is  most  frequently  caused  by  injuries,  and  irri- 
tants such  as  calculi  impacted  within  the  organ  and  suddenly  sub- 
jected by  the  movements  of  the  body  to  some  change  in  position. 
The  suppurations  here  referred  to,  though  often  formed  by  the  fusion 
of  two  or  more  primary  foci,  are  of  a  more  extensive  character  than 
those  which  will  be  brought  under  notice  in  connection  with  what  is 
known  as  surgical  kidney.  Nor  are  they  to  be  confounded  with 
those  chronic  forms  of  suppuration  where  the  whole  organ  is  con- 
verted into  a  sac  of  pus  of  which  the  capsule  and  its  septa  are  the 
boundaries. 

I  am  sx)eaking  of  that  kind  of  suppuration  where  an  abscess  forms 
within  the  confines  of  what  is  practically  a  normal  organ.  Hence  these 
suppurations  are  not  as  a  rule  of  considerable  extent  and  are  usually 


122  HAERISON — DISEASES  OE  THE  KIDNEYS  AND  UEETERS. 

limited,  I  will  say,  to  lialf  an  ounce  or  so  of  matter.  We  may  reason- 
ably assume  if  the  fluid  can  be  evacuated,  or  can  escape  naturally,  re- 
pair may  be  complete.  I  liave  seen  kidneys  containing  foci  of  putty- 
like paste  whick  I  believe,  tkougk  originally  abscesses,  were  in  tke 
course  of  absoption.  Tkere  can  be  no  doubt  tkat  in  some  of  tkese  in- 
stances tke  matter  finds  its  way  into  tke  pelvis  of  tke  kidney  and 
escapes  witk  tke  urine,  recovery  eventually  taking  place. 

Local  and  general  symptoms  of  inflammation  in  tke  neigkborkood 
of  tke  kidney  would  warrant  tke  performance  of  a  lumbar  exploratory 
incision.  In  many  cases  an  opening  kas  resulted  in  tke  discovery 
of  fluid  beneatk  tke  capsule  of  tke  organ,  and  tke  evacuation  of  matter 
kas  been  followed  by  recovery.  Suck  a  proceeding  skould  always 
be  undertaken  wken  persisting  symptoms  point  to  some  structural 
misckief  of  tkis  kind.  I  kave  never  known  karm  result  from  an  ex- 
ploration of  tkis  nature,  even  if  tke  result  kas  been  of  a  negative  ckar- 
acter,  but  on  several  occasions  autopsies  kave  caused  me  to  regret  its 
omission. 

Surgical  Kidney. 

Disseminated  suppurative  nepkritis,  or,  as  it  is  commonly  called, 
surgical  kidney,  differs  materially  from  tke  preceding.  Here  we 
kave  an  illustration  of  tke  septic  effects  on  tkis  organ  of  disease 
originating  in  anotker  part.  Tkis  form  of  suppurative  nepkritis  is 
frequently  seen  in  connection  witk  cystitis  caused  by  tke  presence 
of  tumor,  stricture,  or  enlarged  prostate.  It  is,  in  conjunction  witk 
tke  dilatation  of  tke  ureter  and  of  tke  pelvis  of  tke  kidney,  tke  out- 
come of  obsti'uctive  disease  lower  down,  and  its  presence  seriously 
kandicaps  tke  efforts  of  tke  surgeon  in  removing  wkat  caused  it. 

From  experiments  made  some  years  ago  it  seemed  probable  tkat  if, 
for  tke  purpose  of  remedying  tkat  painful  condition  known  as  extro- 
version of  tke  bladder,  it  was  found  possible  to  connect  tke  ureters 
witk  tke  intestines  and  to  divert  tke  flow  of  tke  urine  in  tkis  way,  the 
emanations  proceeding  from  tke  latter  canal  would  be  sure  to  destroy 
life  by  inducing  a  condition  of  surgical  kidney.  Tkat  tke  ammonia- 
cal  exkalations  from  tke  bladder  are  capable  of  bringing  tkis  about 
tkere  can,  I  tkink,  be  no  doubt. 

Tkis  is  a  form  of  kidney  disorder  wkick  often  proceeds  to  a  fatal 
issue  comparatively  slowly.  Tkougk  usually  occurring  later  on  in 
life,  tke  process  by  wkick  a  normal  kidney  is  converted  into  a  surgi- 
cal one — a  very  inappropriate  designation  by  tke  way — may  be  well 
studied  in,  and  deducted  from,  suck  instances  as  the  one  recorded  in 
a  previous  section  where  a  ruptured  kidney  was  treated  by  Dr.  Raw- 
don  by  nephrectomy.     A  cystitis  from  the  descent  of  foetid  and  de- 


SUEGICAL  KIDNEY.  123 

composing  blood  clots,  in  tlie  first  place,  caused  dilatation  of  the 
ureter  and,  secondly,  the  molecular  suppuration  and  disintegration  of 
the  remaining  organ.  In  its  relation  to  obstructed  urination  and 
surgical  operations  both  of  urgency  and  of  expediency,  it  is  of  chief 
interest  to  the  practitioner  and  moment  to  the  patient. 

The  developmental  process  of  a  septic  or  surgical  kidney  is  mani- 
fested by  symptoms  of  a  general  character  which,  though  not  urgent 
in  themselves,  are  usually  referred  to  as  of  a  low  typhoid  nature.  The 
urinary  invalid,  perhaps  suffering  from  the  difficulties  and  complica- 
tions attendant  upon  a  large  prostate -where  the  use  of  a  catheter  is 
necessary,  becomes  feverish,  his  tongue  is  dry  and  so  usually  is  his 
skin,  the  breath  is  offensive,  there  is  headache  and  emaciation,  and 
sleep,  however  gained,  is  unrefreshing.  -The  blood,  in  fact,  is  charged 
with  products  which  the  kidneys  are  failing  to  eliminate. 

Then  we  have,  following,  variations  in  temperature  of  a  febrile 
character  and  frequently  rigors.  These  are  sometimes  directly  asso- 
ciated with  catheterism  or  the  use  of  instruments,  while  in  other  in- 
stances they  are  not.  These  rigors  are  often  repeated  and  it  has  been 
stated,  but  I  do  not  know  with  what  degree  of  truth,  that  each  re- 
currence marks  the  development  of  a  fresh  focus  of  pus  in  the  kid- 
neys. Profuse  sweating  sometimes  follows  these  manifestations,  and 
thus  the  powers  of  the  patient  are  gravely  taxed.  The  appetite  is 
capricious  and  thirst  is  usually  complained  of.  These  symptoms 
may  spread  themselves  over  many  weeks. 

The  urine  may  vary  in  character ;  it  is  often  purulent  or  ammonia- 
cal.  In  the  earlier  stage,  where  the  disorder  is  limited  to  a  pyelitis, 
though  there  is  pus  in  the  urine,  the  latter  generally  presents  a  dis- 
tinctly acid  reaction.  Both  kidneys  are  usually  involved,  but  in- 
stances of  unilateral  surgical  kidney  are  by  no  means  uncommon. 
Death  generally  occurs  from  exhaustion,  though  in  some  instances 
there  is  complete  suppression  of  urine,  and  the  end  comes  painlessly 
from  uraemia.     The  prognosis  is  most  unfavorable. 

The  treatment  of  this  condition  is  for  the  most  part  preventive, 
and  the  knowledge  of  what  is  likely  to  occur  furnishes  a  sufficient  rea- 
son in  itself  for  the  early  treatment  of  all  forms,  urethral  and  prostatic, 
of  urinary  obstruction.  In  evidence  of  this  we  have  only  to  look  at 
museum  specimens,  where  illustrations  will  be  found,  without  number, 
of  what  is  likely  to  occur  if  strictures  of  any  kind  are  disregarded. 

When  this  condition  has  developed  and  operative  measures,  even 
of  a  comparatively  trivial  kind,  have  to  be  undertaken,  as  for  instance 
the  emx)tying  of  the  atonic  bladder  with  the  catheter,  the  surgeon  will 
do  well,  when  not  compelled  by  any  great  or  sudden  urgency,  to  take 
all  precautions  si)ecially  directed  toward  averting  such  septic  re- 


124  HAEEISON — DISEASES   OF  THE  KIDNEYS  AND  UEETERS. 

suits.  It  was  in  reference  to  wliat  the  late  Sir  Andrew  Clarke  re- 
ferred to  as  catlieter  fever  tliat  the  attention  of  the  profession  was 
first  pointedly  drawn  to  this  particular  aspect  of  the  subject.  Ca- 
theter fever,  as  a  rule,  implies  the  existence  of  a  surgical  kidney, 
though  it  may  not  have  reached  that  stage  pathologically  so  as  to  be 
at  once  apparent  to  the  unaided  eye.  Antiseptic  precautions,  com- 
bined with  the  sterilization  of  the  urine  by  the  use  of  quinine,  bo- 
racic  acid,  salol,  and  the  like,  have  largely  diminished  the  frequency 
of  instances  of  this  kind.  Where  the  state  of  the  bladder  or  of  the 
urine  requires  it,  the  gentlest  form  of  catheterism  with  antiseptic  ir- 
rigation will  often  also  be  required  for  the  purpose  of  preventing  the 
kidneys  being  injuriously  influenced  by  the  presence  of  morbid  excre- 
tions below  them  which  furnish  a  ready  medium  for  the  cultivation 
of  bacteria.  As  a  rule,  the  moderate  use  of  stimulants,  as  in  all  sep- 
tic disorders,  combined  with  nutritious  and  easily  digested  food, 
will  be  required. 

In  reporting  a  case  of  unilateral  surgical  kidney,  occurring  in  a 
patient  upon  whom  nephrectomy  was  j)ractised,  which  was  followed  by 
complete  recovery  of  the  man,  Dr.  Weir  ^  draws  the  following  conclu- 
sions :  "  I  would  consider  it  hereafter  justifiable,  if  the  patient's  gen- 
eral condition  would  warrant  it,  in  a  case  of  acute  septic  invasion  of 
the  kidneys  to  make  on  one  or  both  sides  an  exploratory  incision  not 
only  in  the  hope  of  relieving  the  acute  interstitial  invasion,  but  also 
perhaps  of  encountering  a  larger  and  well-defined  focus  of  pus,  which 
pathological  condition  cannot  always,  it  is  understood,  be  readily  dis- 
criminated from  the  more  dangerous  lesion  of  the  veritable  surgical 
kidney.  Should  the  symptoms  point,  as  in  the  case  narrated,  to  one 
kidney  only,  or  should  a  double  exploratory  incision  show  the  same 
result,  a  nephrectomy  may  with  some  hope  now  be  resorted  to. " 

I  have  already  stated  that,  in  inflammatory  affections  involving  the 
kidney  where  progress  is  not  in  the  direction  of  recovery  so  far  as  the 
local  symptoms  are  concerned,  a  lumbar  exploratory  incision  is  to  be 
commended.  It  has  frequently  led  to  the  discovery  of  an  abscess 
either  within  or  outside  the  capsule  of  the  kidney,  while  in  that  con- 
dition of  tension  which  exists  during  the  process  attending  the  devel- 
opment of  a  surgical  kidney  good  might  reasonably  be  expected  from 
the  adoption  of  a  well-recognized  principle.  A  timely  incision  in  Dr. 
Weir's  case  might  possibly  even  have  averted  the  necessity  for  a  suc- 
cessful nephrectomy.  It  seems  probable  that  the  albuminuria  which 
so  frequently  follows  the  nephritis  observed  in  connection  with  scarlet 
fever  is  largely  due,  in  the  first  instance,  to  the  mechanical  tension 
under  which  during  this  complication  the  urine  is  excreted.  If  we 
had  the  means  of  relieving  this  physical  condition  during  the  process 


SUEGICAL  KIDNEY.  125 

of  a  nephritis  I  do  not  think  we  should  hear  so  much  of  albuminuria 
as  a  sequel  of  this  eruptive  fever.  Nor  do  I  consider  it  as  unlikely 
that  this  principle  of  tension-relieving  by  partial  division  or  puncture 
of  a  fibrous  capsule  will  be  found  on  cautious  trial  capable  of  further 
extension.  I  allude  to  some  of  those  inflammatory  changes  in  the 
secreting  texture  of  the  kidney  which  take  place  in  connection  with 
certain  affections  somewhat  vaguely  referred  to  under  the  name  of 
chronic  nephritis.  I  have  met  with  more  than  one  instance  where  an 
albuminuria  of  some  standing  disappeared  after  an  unsuccessful  explo- 
ration of  a  kidney  for  stone.  How  much  of  this  was  due  to  the  direct 
relieving  of  one  kidney  by  the  removal  of  tension  and  to  the  restora- 
tion of  the  excretory  balance  thus  effected,  is  a  matter  affording  in- 
teresting speculation. 

In  a  paper  on  nephritis  Dr.  Keyes"  has  drawn  the  following  deduc- 
tions in  relation  to  the  circumstances  under  which  surgical  kidney  is 
produced:  "(1)  To  use  reasonable  care  in  exploring  a  healthy 
bladder  or  passing  any  instrument  into  it ;  (2)  To  use  greater  care  if 
there  be  traumatism  from  stone,  tumor,  stricture,  esjjecially  if  the 
powers  of  the  individual  be  weakened  by  age  or  disease ;  (3)  To  ex- 
ercise every  known  precaution  in  exploring  and  manix^ulating  in- 
strumentally  cases  of  dilated  bladder  in  a  fibrotic  stage  with  en- 
larged ureters  and  damaged  kidneys."  These  no  doubt  represent 
varying  degrees  of  susceptibility. 

Eenal  fistula  are  of  two  kinds,  namely,  those  opening  externally 
as  in  the  loin,  and  those  communicating  with  internal  viscera  such  as 
the  intestines.  They  are  usually  caused  by  wounds  involving  the 
kidney,  such  as  stab-wounds  or  gunshot  injuries,  as  well  as  by  incisions 
in  the  course  of  surgical  procedures  for  the  opening  of  abscesses  and 
the  removal  of  renal  calculi.  Less  frequently  they  have  followed  upon 
suppurations  within  the  pelvis  and  cortex  of  the  kidney.  In  some 
instances  they  appear  to  have  served  the  purpose  of  providing  a 
spontaneous  means  of  escape  for  calculi  and,  where  the  ureter  has 
been  permanently  obstructed,  of  furnishing  a  vent  for  the  urine. 
Though  externally  they  are  most  frequently  found  in  the  loin,  they 
have  occasionally  opened  as  low  down  as  the  groin.  Their  urinous 
character  is  at  once  obvious,  though  the  discharge,  especially  where 
their  origin  is  of  a  tuberculous  nature,  is  usually  more  or  less  mixed 
with  i)us. 

Where  the  sinuses  have  opened  into  internal  organs  some  remark- 
able symptoms  have  been  the  result.  Morris'  refers  to  a  well  authen- 
ticated case  where  a  woman  after  an  attack  of  renal  colic  and  reten- 
tion of  urine  vomited  coffee-colored  gravel  and  passed  small  stones 
by  the  mouth,  rectum,  and  urethra.     This  is  stated  to  have  been  an 


126  HARRISON — DISEASES   OF  THE  KIDNEYS  AND  URETERS. 

instance  where  a  fistula  connected  the  kidney  with  the  stomach.  Some 
supposed  examples  of  internal  lesions  of  this  nature,  however,  have 
turned  out  to  be  impositions,  and  therefore  the  practitioner  must  be 
on  his  guard  before  accepting  such  a  conclusion.  Morris  records  a 
case  where  an  autopsy  showed  a  renal  fistula  communicating  with  the 
left  end  of  the  great  curvature  of  the  stomach.  The  same  author 
refers  to  some  instances  of  fistulse  opening  into  the  intestines  as  well 
as  the  lung.  The  former  condition  will  probably  explain  some  of 
those  instances  where  air  is  voided  with  the  urine  by  the  urethra. 

The  treatment  of  a  renal  fistula  is  entirely  dependent  upon  the  cir- 
cumstances surrounding  it.  Those  following  a  simple  incision  or 
wound  uncomplicated  with  any  serious  structural  disease  of  the  organ 
usually  close  with  treatment  such  as  is  appropriate  to  all  sinuses  re- 
sulting from  the  imperfect  healing  of  a  deep  opening  of  this  nature. 
The  aftplication  of  well-recognized  surgical  principles  almost  invaria- 
bly suffices.  Failures  after  a  sufficient  trial  are  suggestive  that  a 
more  serious  condition  of  the  kidney  than  was  expected  may  exist. 
An  exploration  and,  if  not  more  is  found  necessary,  a  curetting  of  the 
sinus  may  in  a  chronic  case  be  required.  Some  cases  of  renal  fistulae 
fail  to  heal  because  the  corresponding  ureter  is  either  partially  or 
completely  obstructed. 

I  have  recently  seen  a  case  of  this  kind  in  which  a  renal  abscess 
followed  upon  an  injury  to  the  loin,  and  for  some  years  the  patient  has 
passed  a  considerable  quantity  of  his  urine  through  the  sinus.  He 
collects  it  by  means  of  an  apparatus  which  causes  him  but  little  in- 
convenience. That  he  has  no  prospect  of  getting  rid  of  his  inconven- 
ience without  extirpation  of  the  kidney  I  have  not  the  least  doubt, 
as  examination  of  his  bladder  by  the  electric  cystoscope  clearly  shows 
that  the  ureter  is  obstructed.  With  this  instrument  the  pumping 
action  of  one  ureter  can  be  plainly  demonstrated,  while  in  the  other 
it  is  absent.  As  the  patient's  health  is  excellent  and  the  urine  is 
normal  and  the  question  of  convenience  is  not  advanced,  I  should  not 
consider  the  extirpation  of  the  involved  kidney  justifiable. 

Cases  of  this  nature — and  there  are  not  a  few  of  them — seem  to 
have  an  important  bearing  upon  the  treatment  of  the  most  serious 
forms  of  deformity  of  the  bladder.  Eeference  will  be  found  to  this 
aspect  of  the  subject  in  my  article  on  diseases  of  this  organ.  The  im- 
portance of  the  electric  cystoscope  in  enabling  us  to  determine  as 
to  whether  a  patient  has  one  or  two  working  kidneys  will  now,  I 
think,  be  generally  acknowledged. 

Passing  to  other  instances  of  renal  fistula  illustrations  will  be  met 
with  where  there  can  be  no  doubt,  from  evidence  afforded  partly  by 
the  local  condition  and  partly  by  the  state  of  the  general  health,  that 


HTDB0NEPHE0SI8.  127 

the  kidney  with,  which  they  are  connected  is  to  all  intents  and  pur- 
poses a  foreign  body.  Like  a  joint  or  a  limb  it  may  have  passed  into 
a  pathological  condition  which  renders  its  retention  eventually  as  a 
part  of  a  healthy  or  a  living  body  absolutely  impossible.  Under  such 
circumstances  nephrectomy  after  exploration  must  be  proceeded  with 
as  in  the  analogous  illustrations  I  have  taken,  where  the  removal  of 
diseased  parts  becomes  obvious.  A  similar  course  of  action  will  be 
called  for  in  those  instances  where  the  evidence  is  sufficient  to  show 
that  a  renal  fistula  is  the  cause  of  some  progressive  disease  in  an  ad- 
jacent internal  organ. 

An  exploratory  operation  or  nephrotomy  should,  as  a  rule,  be  se- 
lected before  adopting  the  more  radical  procedure,  as,  if  found  neces- 
sary, the  latter  may  follow  upon  the  former  without  adding  to  the  diffi- 
culties or  risks  connected  with  it.  It  is  under  such  circumstances 
that  the  great  value  of  the  lumbar  method  as  against  the  abdominal 
becomes  apparent.  Many  instances  of  fistula  dependent  upon, calculi, 
suppurations,  hydatids,  and  the  like  have  been  completely  remedied  by 
a  sufficient  incision  for  a  digital  exploration  of  the  part.  Unfortu- 
nately I  cannot  put  my  finger  on  the  record,  but  I  have  a  distinct 
recollection  of  reading  a  well-narrated  case  where  a  lAn  or  needle 
covered  with  phosphates  was  successfully  removed  from  a  kidney 
through  the  loin  and  proved  to  be  the  cause  of  a  fistula,  hsematuria, 
and  purulent  urine. 

Hydronephrosis. 

Hydronephrosis  is  a  term  applied  to  the  dilatation  which  the  pelvis 
and  calyces  of  the  kidney  undergo  by  the  pressure  of  the  urine  when 
the  latter  is  prevented  escaping  in  a  natural  manner  into  the  bladder. 
It  is  as  if  a  band  were  gradually  drawn  round  the  ureter  while  the 
excretion  by  the  kidney  continued.  Hence  the  term  indicates  a  varia- 
ble state  of  distention  and  the  implication  of  one  or  both  organs  in 
the  process.  When  extreme  it  may  result  in  the  absorption  by  pres- 
sure of  the  entire  excreting  portion  of  the  gland  and  the  ultimate  con- 
version of  the  kidney  into  a  fibrous  bag  containing  fluid,  of  which  the 
capsule  and  the  septa  are  the  boundaries.  When  the  process  is 
limited  to  one  kidney,  the  opposite  organ  often  proves  equal  to  meet- 
ing the  requirements  for  the  entire  excretion  of  urine,  but  the  con- 
dition obviously  becomes  extremely  serious  when  both  kidneys  are 
implicated  in  the  cause  upon  which  the  hydronephrosis  primarily 
depends. 

With  such  a  definition  before  us  it  will  not  be  very  difficult  to 
recognize  the  various  circumstances  under  which  one  or  both  ureters 
may  be  subjected  to  a  degree  of  i)ressure  sufficient  to  bring  about 


128  HAEEISON— DISEASES   OF  THE  KIDNEYS  AND  URETERS. 

sucli  clianges  in  tlie  kidney.  In  tlie  first  place,  we  liave  evidence 
tliat  hydroneplirosis  is  sometimes  the  result  of  congenital  defects 
in  tlie  ducts.  Folds,  twists,  valves,  and  obliquities  in  tlie  mode 
of  entering  tlie  bladder,  in  tlie  ureters  have  been  found  explanatory 
of  this  effect.  In  a  case  recorded  by  Sir  William  Boberts  in  his 
treatise  on  "Urinary  and  Renal  Diseases,"  the  pressure  of  an  anom- 
alous branch  of  a  renal  artery  appeared  sufficient  to  cause  it. 
Various  malformations  in  the  course  of  the  ureters  and  their  rela- 
tions Avith  the  kidneys  have  also  been  described  as  associated  with 
hydronephrosis . 

The  accidental  causes  of  ureteral  obstruction  are  equally  various. 
In  an  analysis  of  142  cases  of  hydronephrosis  Morris  mentions  nu- 
merous causes  for  interference  with  the  descent  of  the  urine  into  the 
bladder,  of  which  cancer  invohing  parts  within  the  pelvis  appears  to 
be  the  most  frequent.  Cystitis,  vesical  calculus,  villous  growth  of  the 
bladder,  enlarged  prostate,  hydatid  and  ovarian  cysts  are  also  enu- 
merated. Out  of  these  142  cases  which  include  various  degrees  of 
hydronephrosis  106  seem  to  have  implicated,  more  or  less,  both  kid- 
neys. Dr.  L.  Landau*  has  drawn  attention  to  some  cases  of  intermit- 
ting hydronephrosis  observed  in  women,  which  he  connects  with  a 
twisting  or  "  kinking"  of  the  ureber  belonging  to  the  kidney  involved. 
The  symptoms  in  some  degree  resembled  those  of  renal  colic  con- 
nected with  stone,  and  were  accompanied  with  tumefaction  of  a  vary- 
ing character  in  the  region  of  the  kidney.  In  two  of  the  instances  re- 
corded the  symptoms  disappeared  during  pregnancy — a  circumstance 
which  was  explained  by  the  movable  kidney  being  fixed  in  position 
by  the  gra^dd  uterus.  In  one  case  relief  was  afforded  by  an  abdom- 
inal bandage.  It  is  in  cases  such  as  this  that  well-directed  massage 
temporarily  removes  both  swelling  and  pain.  Then  we  have  lesions 
and  injuries  to  the  ureters  which  chiefly  affect  one  side  only ;  of  these 
I  may  mention  stones  impacted  in  the  ducts  and  contractions,  or 
strictures,  resulting  from  injuries  to  these  tubes. 

In  1883  I  was  consulted  by  a  gentleman  from  South  America  about 
an  injury  he  had  received  in  the  right  loin  from  a  bullock  on  a  cattle 
ranch.  The  injury  was  not  attended  with  an  external  wound,  but 
there  was  a  severe  contusion  of  the  part;  it  was  followed  by  haema- 
turia,  and  more  remotely  by  right  hydronephrosis,  for  which  aspira- 
tion had  been  repeatedly  employed.  The  point  raised  was,  if  the 
ureter  is  merely  strictured,  and  not  completely  ruptured,  can  any- 
thing be  attempted  to  save  the  kidne"y  from  atrophy?  As  it  seemed 
probable  the  ureter  had  been  divided,  and  the  corresponding  kidney 
was  rapidly  being  atrophied,  I  came  to  the  conclusion  that  it  was  ad- 
visable that  nothing  should  be  done,  and  I  have  since  heard  the 


HYDEOKEPHEOSIS.  129 

patient  lias  completely  recovered  his    health,  though  there  can  be 
no  doubt  he  has  lost  a  kidney. 

The  following  case,  recorded  by  Mr.  W.  J.  Collins  in  a  paper  on 
traumatic  hydronephrosis,"  is  of  much  interest  in  connection  with  the 
diagnosis  and  treatment  of  these  injuries : 

Case. — G.  W.,  aged  5,  was  admitted  into  the  London  Temperance 
Hospital  on  November  5th,  1889,  in  a  collapsed  state,  having  been 
run  over  by  a  cart,  the  wheel  passing  over  the  abdomen  anci  pelvis. 
There  was  fracture  of  the  left  lower  ribs  and  of  the  right  os  innomi- 
natum  near  the  eminentia  ilio-pectinea.  The  collapse  suggested  vis- 
ceral lesion ;  the  catheter  drew  off  only  a  drachm  or  two  of  sanious 
urine.  However,  injection  of  the  bladder  with  two  ounces  of  boracic- 
acid  solution,  and  the  subsequent  recovery  of  the  same  quantity  by 
bimanual  expression,  proved  that  this  viscus  was  unruptured.  For 
some  days  the  urine  was  blood-stained,  but  he  made  a  good  recovery 
and  was  discharged  on  November  SOth,  passing  about  twenty-three 
ounces  of  urine  per  diem.  A  week  later  he  was  readmitted  on  account 
of  a  painless  swelling  discovered  in  the  right  loin,  extending  above  to 
the  hypochondrium,  below  to  Poupart's  ligament,  and  inward  to  the 
navel.  The  colon  was  easily  felt  in  front  of  the  tumor ;  there  was 
fluctuation.  On  deep  palpation  in  the  right  inguinal  region  a  hard, 
sessile  mass  was  felt  at  or  near  the  pelvic  brim,  which  was  presumed 
to  be  callus  at  the  site  of  the  pelvic  fracture.  There  was  neither  pain 
nor  fever,  and  the  general  condition  was  good.  The  urine  was  nor- 
mal, but  was  reduced  to  less  than  half  a  pint  per  diem,  sometimes 
only  six  ounces.  December  10th,  1889,  the  tumor  was  aspirated  from 
the  loin,  withdrawing  18  ounces  of  pale  amber-colored  fluid,  of  specific 
gravity  1.003,  faintly  alkaline,  containing  a  trace  of  albumin  and  one  per 
cent  of  urea.  The  swelling  rapidly  returned,  and  on  December  16th, 
20th,  and  30tli  was  again  aspirated,  withdrawing  25,  29,  and  30  ounces 
respectively.  Since  this  date  it  was  aspirated  at  increasing  intervals 
down  to  May  21st,  1891,  the  patient  coming  for  this  purpose  as  re- 
accumulation  occurred.  There  were  sixteen  aspirations  in  all.  Since 
May,  1891,  there  has  been  no  appreciable  return  of  the  swelling,  and 
the  boy  is  in  excellent  health. 

The  still  more  remote  effects  of  these  injuries  relative  to  the  for- 
mation of  a  stricture  of  the  ureter  and  hydronephrosis  are  exemplified 
in  the  following  record  by  Dr.  Pye-Smith  " : 

Case. — "The  patient  was  24  years  of  age.  About  two  years  pre- 
viously to  his  coming  into  Guy's  Hospital  he  had  been  kicked  by  a 
horse  on  the  left  side  '  under  the  short  ribs. '  This  was  followed  by 
hsGmaturia.  On  his  admission  to  the  hospital  there  was  a  large  tumor 
occupying  the  left  half  of  the  abdomen,  the  physical  character  of 
which  xKnnted  to  its  connection  with  the  kidney.  The  tumor  was 
taj>ped,  and  a  large  quantity  of  fluid  removed.  After  death  the  left 
kidney  was  found  to  be  in  a  condition  of  cystic  degeneration.  The 
ureter  was  dilated  for  an  inch  and  a  half,  when  it  suddenly  became 
Vol.  I.— 9 


130  HAERISON — DISEASES  OF  THE  KIDNETS  AM)  UEETEES. 

contracted,  so  as  not  to  admit  tlie  smallest  probe.    A  few  lines  nearer 
to  tlie  bladder  it  again  assumed  its  normal  size." 

These  instances  are  sufficient  to  illustrate  most  of  tlie  points  con- 
nected witli  tlie  causation  of  traumatic  hydronephrosis. 

In  some  cases  a  hydronephrosis  appears  to  be  intermittent ;  at  one 
time  the  renal  tumor  is  tense,  while  at  another  it  is  soft  and  compres- 
sible, indicating  a  variation  in  the  amount  of  its  fluid  contents.  There 
can  be  no  better  guide  in  the  diagnosis  of  these  conditions  than  the 
recognition  of  the  fact  that  a  sudden  increase  in  the  voluntary  dis- 
charge of  urine  is  immediately  followed  by  a  corresponding  diminu- 
tion in  bulk  of  the  swelling  occupying  the  region  of  the  loins.  Dr. 
James  reports  a  case  "  in  which  he  considered  that  the  contraction  of 
the  bladder  due  to  frequent  micturition  was  the  origin  of  a  hydrone- 
phrosis, and  Morris  shows  that  this  explanation  may  be  extended  to 
other  causes  leading  to  a  considerable  straining,  such  as  phimosis 
and  prostatic  enlargement. 

In  illustrating  how  the  ureter  is  obstructed  it  might  be  inferred 
that  hydronephrosis  necessarily  follows,  but  this  is  not  invariably  the 
case.  In  some  instances  of  occlusion  from  rupture  and  injury  to  the 
ureter  where  there  is  risk  of  urine  being  extravasated  into  the  sub- 
peritoneal tissues,  I  have  concluded  from  examinations  made  by  my- 
self as  well  as  by  others  that  extensive  renal  thrombosis  is  frequently 
an  immediate  sequence  of  an  injury  of  this  kind.  Thus  urinary  ex- 
cretion is  modified  by  the  more  or  less  vascular  consolidation  of  the 
organ  involved,  and  the  most  serious  complication  attending  such  in- 
juries is  averted.  This  I  believe  proves  to  be  the  first  step  in  the 
process  of  renal  atrophy,  in  contradistinction  to  dilatation,  which 
subsequently  follows.  Mr.  Poland  and  Dr.  Moxon  have  both  shown 
that  the  blood-vessels  of  a  kidney  which  has  been  injured  are  some- 
times found  to  be  entirely  infarcted.  This  point  will  again  be  re- 
ferred to  in  connection  T\dth  injuries  to  the  ureters. 

The  fluid  contained  in  hydronephrotic  kidneys  is  usually  urine  of 
a  very  dilute  character,  containing  traces  of  the  natural  constituents. 
It  is  nearly  always  more  or  less  albuminous.  Prout  detected  urea 
and  uric  acid  in  the  contents  of  a  double  hydronephrosis  from  a  still- 
born infant.  In  an  analysis  made  by  Sir  William  Roberts  the  cyst 
contained  83  ounces  of  clear  fluid  of  a  pale  lemon  color  and  urinous 
smell,  sp.  gr.  1.002,  very  slightly  acid,  with  the  faintest  trace  of 
albumin  and  presenting  under  the  microscope  a  few  broken-down 
cells  of  large  size.  Occasionally  the  contents  of  the  sac  are  of  a  col- 
loid nature. 

Hydronephrosis  need  not  necessarily  go  on  to  the  complete  de- 
struction of  the  organ.     In  the  case  of  calculi,  the  obstruction  may  be 


HYDEONEPHBOSIS.  131 

dislodged  and  the  sac  emptied  without  further  accumulation.  Again 
instances  are  recorded  where  a  frequent  emptying  of  the  cyst  artifi- 
cially has  eventually  ended  in  the  atrophy  of  the  organ,  its  place  being 
supplied  by  the  growth  of  its  fellow. 

The  symptoms  of  hydronephrosis  are  extremely  variable  and  are 
much  dependent  upon  the  size  which  the  sac  or  sacs  have  attained. 
In  the  majority  of  instances  no  abdominal  encroachment  can  be  made 
out.  On  the  other  hand,  cases  are  occasionally  met  with  where  these 
sacs  attain  such  dimensions  as  to  simulate  dropsies,  and  instances  are 
recorded  where  operations  have  been  undertaken  under  the  belief  that 
ovariotomy  was  indicated.  In  a  case  cited  by  Mr.  Glass  '^  where  thirty 
gallons  of  light  coffee-colored  limpid  fluid  were  withdrawn  after  death 
from  a  huge  sac  representing  the  right  kidney,  the  circumference  of 
the  abdomen  was  found  to  be  six  feet  four  inches,  and  from  the  ensi- 
form  cartilage  to  the  os  pubis  it  measured  four  feet  and  half  an  inch. 
The  left  kidney  and  ureter  were  healthy. 

Passing  to  the  opposite  extreme  it  will  be  found  that  instances  are 
frequently  met  with  where  hydronephrotic  kidneys  are  discovered  after 
death  which  do  not  appear  to  have  occasioned  any  physical  signs  or 
objective  symptoms  during  life.  Hence  I  shall  proceed  to  consider 
those  examples  where  there  is  some  evidence  of  renal  enlargement. 
When  limited  to  one  kidney  the  condition  of  the  urine  is  not  at  all 
likely  to  furnish  any  clue,  as  the  opposite  one  is  quite  able  to  main- 
tain the  natural  characteristics  of  the  excretion.  Under  such  circum- 
stances surgical  interference  in  a  case  of  renal  enlargement  presenting 
an  indistinct  sensation  of  fluctuation  would  hardly  be  warranted  unless 
inconvenience  or  pain  were  occasioned  by  the  dimensions  of  the 
growth.  Then  a  lumbar  aspiration  would  be  indicated  when  the 
nature  of  the  swelling  might  probably  be  with  more  accuracy  de- 
termined. In  some  instances  such  a  proceeding  has  been  followed 
by  a  gradual  disappearance  of  the  swelling. 

When  there  are  similar  reasons  for  believing  that  both  kidneys 
are  involved,  should  either  or  both  reach  such  dimensions  as  have 
just  been  referred  to,  the  aspirator  may  be  employed  in  the  same 
way.  Under  the  latter  circumstances,  however,  we  are  much  more 
likely  to  meet  with  symptoms  of  ursemia  superadded  to  the  local 
distress,  and  rendering  the  prospects  of  the  patient  extremely  bad. 
The  efforts  of  the  physician  may  here  be  directed  toward  elimi- 
nating X)roducts  which  the  kidneys  have  little  chance  of  doing.  Much 
may  doubtless  be  done  both  by  medicine  and  by  diet  in  this  way. 

A  case  illustrating  several  points  in  the  pathology  and  treatment 
of  hydronei)hrosis  has  recently  come  under  my  notice,  and  some 
reference  may  be  made  to  it  here.     It  was  that  of  a  middle-aged  man, 


132  HAERISON — DISEASES  OP  THE  KIDNEYS  AND  URETEES. 

long  resident  in  Australia  where  the  disease  had  probably  been  con- 
tracted, suffering  from  hydatids  within  the  pelvis.  The  disease  was 
of  several  years'  standing  on  his  arrival  in  this  country,  and  formed  a 
tumor  of  considerable  size.  It  appeared  to  be  situated  in  the  space 
between  the  bladder  and  the  rectum  outside  the  peritoneal  cavity. 
It  formed  a  prominence  in  the  left  hyi)ochondrium,  the  bladder  being 
pushed  over  toward  the  opposite  side.  It  was  impossible,  by  reason 
of  the  angle  given  to  the  urethra,  to  pass  a  rigid  instrument  such  as  a 
catheter  into  the  bladder,  but  a  long,  flexible  bougie  was  readily  in- 
troduced. On  passing  the  finger  into  the  rectum  the  prostate  was  to- 
tally obscured  by  what  felt  like  a  solid  mass  about  as  large  as  a  foetal 
head.  In  this  way  the  pelvis  may  be  said  to  have  been  completely 
blocked.  During  the  last  few  weeks  both  defecation  and  urination 
had  become  well-nigh  impossible  in  spite  of  all  kinds  of  expedients. 
The  pain  on  these  occasions  was  most  excruciating,  to  relieve  which 
the  patient  of  his  own  accord  took  large  doses  of  morphine  amounting 
frequently  to  over  six  grains  a  day. 

Various  opinions  had  been  expressed  in  reference  to  the  diagnosis, 
but  I  do  not  think  a  definite  conclusion  was  arrived  at  until  I  acci- 
dentally discovered  booklets  in  the  faeces.  This  gave  the  clue  to  the 
case.  The  other  symx)toms  were  due  to  the  great  pressure  exercised 
within  the  pelvis.  Both  kidneys  were  hydronephrotic,  the  ureters 
largely  dilated,  and  the  intestines  distended  and  impacted  with  faeces. 
By  degrees  this  state  of  abdominal  and  pelvic  infarction  became  com- 
plete, and  it  was  difficult  to  know  what  was  best  to  be  done  for  the 
patient.  A  laparotomy  appeared  out  of  the  question,  and  to  open  and 
drain  the  cyst  by  a  direct  incision  through  the  abdominal  wall  did 
not  in  the  matter  of  subsequent  drainage  commend  itself  to  me. 

Mr.  Durham  was  good  enough  to  see  the  case  with  me  and  Mr. 
Band.  After  a  very  careful  consideration  from  all  i^oints  of  view  we 
came  to  the  conclusion  that  it  would  be  best  to  open  the  cyst  from  the 
perineum  between  the  bladder  and  rectum,  and  thus  to  empty  and 
drain  the  cavity.  This  was  accordingly  done,  and  I  made  my  perineal 
incision  just  as  if  I  was  performing  a  lateral  lithotomy  but  without 
opening  the  urethra.  The  position  of  the  latter  was  indicated  to  me 
by  a  flexible  bougie  passed  into  the  bladder.  I  then  made  my  way 
between  the  prostate  and  the  rectum  until  the  cyst  was  reached.  This 
was  freely  opened  by  incision,  when  a  large  mass  of  hydatids  suf- 
ficient to  overfill  a  quart  vessel  was  evacuated,  the  process  of  extru- 
sion being  assisted  by  abdominal  pressure  and  the  use  of  a  lithotomy 
scoop.  There  was  very  little  hemorrhage.  A  large  gum-elastic 
drainage-tube  was  introduced  and  secured. 

A  number  of  daughter  cysts  were  subsequently  passed  and  free 


HYDEONEPHROSIS.  133 

drainage  and  irrigations  were  maintained.  Tlie  hydronephrotic  con- 
dition gradually  subsided,  and  in  the  course  of  a  short  time  the  dis- 
tended abdominal  viscera  had  gradually  returned  toward  their  nor- 
mal dimensions.  The  patient  was  able  to  go  home  at  the  end  of  three 
weeks  from  the  private  hospital  where  the  operation  was  performed. 
The  perineal  wound  still  continued  to  drain,  and  the  only  symptoms 
the  patient  had  to  overcome  were  those  directly  due  to  the  morphine 
habit  which  by  reason  of  his  previous  sufferings  he  had  acquired. 
The  distention  of  the  abdomen,  partly  by  the  hydatids  and  partly 
by  the  enlargement  proceeding  from  the  intestines  and  the  hydro- 
nephrotic  ureters  and  kidneys,  rendered  the  case  a  remarkable  one. 

In  the  treatment  of  hydronephrosis  it  must  not  be  forgotten  that 
in  some  this  condition  is  due  to  the  impaction  of  the  ureter  by  a 
calculus  or  even  by  a  plug  of  necrotic  renal  tissue.  This  would  not 
be  unlikely  in  a  case  where  the  local  signs  had  been  preceded  by  the 
history  of  renal  colic,  or  by  the  escape  of  renal  calculi  by  the  urethra. 
Under  such  circumstances  a  trial  should  be  made  to  facilitate  the 
extrusion  of  the  obstruction  from  the  ureter,  as  by  the  use  of  manipu- 
lation and  shampooing  of  the  loin.  Two  instances  at  least  of  this 
nature  are  reported,  one  by  Sir  William  Broadbent  (referred  to  by 
Morris)  and  the  other  by  Sir  William  Boberts,  where  the  loin  tumors 
subsided  under  such  efforts. 

It  is  remarkable  how  little  it  sometimes  takes  to  induce  a  calculus 
to  move  downward,  and  where  a  ureter  is  more  or  less  permanently 
dilated,  as  in  the  case  of  persons  who  frequently  pass  calculi,  the 
explanation  is  obvious.  Reference  has  been  made  by  me  to  the  fact  '^ 
that  the  injection  of  water  into  the  bladder  so  as  to  distend  it  has 
occasionally  proved  of  assistance  in  favoring  the  release  of  a  calculus 
down  the  ureter.  This  process  has  also  been  found  of  service  in 
expediting  the  discharge  of  tuberculous  debris  from  the  kidney.  It 
would  probably  also  be  useful  in  those  exceptional  cases,  such  as  the 
one  recorded  by  Dr.  Rattray  and  Mr.  Greig  Smith,"  where  sloughs  of 
renal  tissue  made  their  escape  by  the  urethra.  Again  it  is  of  ad- 
vantage in  suppurative  pyelitis,  by  assisting  the  escape  of  matter 
downward.  It  has  been  noted  that  after  its  adoption  high  tempera- 
tures from  the  retention  of  pus  have  ceased.  Here  causes  are  enu- 
merated suflS.cient  to  start  or  maintain  a  hydronephrosis. 

Reference  has  already  been  made  to  the  difficulty  that  exists  in 
determining  between  a  large  hydronephrosis  and  an  ovarian  cyst.  A 
somewhat  similar  difficulty  may  also  occur  in  the  case  of  ascites  and 
hydatid  cysts.  A  dilated  kidney  can  generally  be  recognized  by  the 
colon  being  in  front  of  the  swelling,  and  by  the  absence  of  resonance 
in  the  lumbar  region.     Further,  much  direct  information  relative  to 


134  HAERISON — ^DISEASES  OF  THE  KIDNEYS  AOT)  URETERS. 

an  ovarian  cyst  may  be  obtained  by  a  vaginal  examination.  Ascites 
often  coexists  with  advanced  hydronephrosis,  but  the  changes  in  the 
level  of  the  fluid  arising  out  of  altered  positions  of  the  body  usually 
enable  us  to  recognize  this  dropsical  condition.  Hydatids  may  be 
suspected  by  the  presence  of  a  characteristic  fremitus  as  well  as  by 
vesicles  in  the  urine. 

Taking  the  instance  of  a  single  hydronephrosis  which  continues  to 
fill  and  cause  pain  or  inconvenience,  in  spite  of  the  repetition  of  as- 
piration, what  further  steps  can  be  taken?  The  more  radical  meas- 
ures of  nephrotomy,  or  opening  the  kidney  from  the  loin  and  drain- 
ing until  the  sac  either  consolidates  or  is  reduced  to  the  condition  of 
an  innocuous  sinus,  or  the  still  more  complete  measure  of  nephrectomy 
or  removal  of  the  kidney,  have  both  been  recommended  and  practised. 
I  am  in  favor  of  the  former  and  would  prefer  its  adoption,  unless  the 
necessary  exploration  through  the  loin  that  this  entails  leads  to  the 
discovery  of  a  kidney  which  is  completely  disorganized.  In  the  latter 
case  a  prolonged  suppuration  would  certainly  overtax  the  strength 
and  endurance  of  the  patient,  and  nephrectomy  is  indicated.  These 
two  operations  will  be  described  later  on. 

Pyonephrosis. 

Suppuration  involving  the  pelvis  of  the  kidney,  however  produced, 
may,  by  obstruction  of  the  ureter  incidental  to  such  a  condition,  lead 
to  the  dilatation  of  the  kidney  and  its  conversion  into  a  pus-contain- 
ing sac.  As  with  hydronephrosis,  a  bag  of  fluid  bounded  by  the 
capsule  and  its  septa  may  be  thus  substituted  for  the  natural  organ. 

A  hydronephrosis  may  become  a  pyonephrosis  by  the  intercurrence 
of  suppuration,  and  the  causes  of  the  former  are  among  those  of  the 
latter.  One  or  both  kidneys  may  be  involved  in  varying  degrees,  as 
we  see  in  cases  such  as  those  of  enlarged  prostate  with  cystitis,  and 
in  the  more  advanced  forms  of  urethral  stricture.  Of  all  the  causes 
of  pyonephrosis  the  presence  of  a  calculus  within  the  kidney  is  by 
far  the  most  common,  so  much  so  that  some  have  thought  the  term 
calculous  pyelitis  would  be  generally  applicable.  This,  however,  is 
not  the  case,  as  numerous  examples  of  very  extensive  pyelitis  and 
distention  are  the  direct  result  of  tubercular  disease  either  in  the 
kidney  or  its  duct. 

Instances  occur  where  there  can  be  no  doubt  the  obstruction  in 
the  ureters  and  the  pyelitis  were  directly  due  to  the  general  invasion 
of  the  urinary  organs  with  the  gonorrhoeal  bacteria.  These  represent 
some  of  the  most  acute  forms  of  the  disorder,  and  death  not  unfre- 
quently  happens  from  uraemia. 


PYONEPHROSIS.  135 

The  pent-up  pus  and  urine  in  a  pyonephrotic  kidney  will  often 
escape  intermittently  along  the  ureter.  Here  the  secretion  in  the 
first  instance  generally  presents  an  acid  reaction  and  is  charged  with 
pus  which  gradually  falls  to  the  bottom  of  the  glass  on  standing  for 
some  time.  When  the  matter  cannot  escape  freely  in  this  way,  ulcera- 
tion of  the  capsule  may  occur  and  the  contents  of  the  sac  find  their 
way  in  various  directions,  as  through  the  loin,  along  the  psoas  muscle 
into  the  iliac  fossa,  under  Poupart's  ligament,  or  even  into  the  cavity  of 
the  peritoneum.  In  some  instances  it  has  penetrated  the  diaphragm 
and  escaped  through  the  bronchi,  while  in  others  some  part  of  the 
intestines  has  been  opened  into.  Such  are  the  numerous  directions 
in  which  a  vent  may  be  found  for  an  abscess  of  this  nature  when  left 
to  itself. 

Ammoniacal  decomposition  of  urine  within  the  kidney  may  lead 
to  the  interior  of  this  organ  being  largely  encrusted  by  a  soft,  phos- 
phatic,  mortar-like  substance  which  shows  a  tendency  to  adhere 
wherever  the  surface  is  rendered  rough  or  uneven.  Sir  William 
Roberts  states  that  fibrous  septa  within  the  kidney  are  sometimes 
calcified,  and  he  refers  to  an  instance  where  in  examining  a  specimen 
of  this  kind  it  was  necessary  to  cut  the  kidney  across  with  a  saw. 
Microscopical  examination  of  a  portion  showed  the  characters  of  true 
bone,  though  in  a  rudimentary  state. 

The  early  symptoms  of  this  affection  are  those  of  pyelitis.  Refer- 
ence has  already  been  made  to  the  surgical  conditions  under  which  it 
most  frequently  occurs.  From  this  point  of  view  we  are  chiefly  in- 
terested, with  the  knowledge  before  us  of  what  is  likely  to  occur,  in 
preventing  obstructive  disorders  leading  to  such  a  state  of  disor- 
ganization. Urethral  strictures  and  prostatic  enlargement  furnish 
examples  of  causes  most  likely  to  produce  these  effects  unless  dealt 
with  in  good  time  by  suitable  measures.  In  some  instances  of  this 
kind  renal  tumefaction  can  be  discovered,  and  when  in  conjunction 
with  this  we  have  rigors  and  variations  in  temperature  the  retention  of 
pus  is  rendered  probable.  Some  of  these  cases  terminate  in  complete 
suppression  of  urine  extending  over  three  or  four  days  before  death 
occurs. 

The  most  acute  forms  of  suppurative  pyelitis  may  be  seen  in  con- 
nection with  the  cystitis  arising  out  of  urethral  obstruction,  and 
require  prompt  treatment  by  perineal  cystotomy  with  drainage,  as 
referred  to  in  the  section  relating  to  cystitis. 

Where  the  case  is  of  a  less  acute  character  and  there  is  such  an 
amount  of  renal  tumefaction  as  to  render  dilatation  with  pus  and 
urine  likely,  an  exx)loration  should  be  made.  This  is  best  done  in 
the  first  instance  with  the  aspirator  needle  from  the  loin,  the  surgeon 


136  HAEEISON — DISEASES   OF  THE  KIDNEYS  AND  UKETEES. 

being  prepared,  if  evidence  of  pyonephrosis  is  afforded,  to  proceed 
to  open  tlie  kidney  for  the  purpose  of  digital  exploration  and  drain- 
age. In  a  certain  proportion  of  cases  where  the  disorder  is  not  far 
advanced,  though  palpable  enlargement  of  the  organ  has  occurred, 
and  the  obstruction  is  removable  either  by  the  withdrawal  of  a  calculus 
from  the  pelvis  of  the  kidney  or  its  spontaneous  escape  along  the 
ureter,  recovery  after  opening  and  drainage  may  occur.  If,  however, 
the  kidney  is  completely  disorganized,  its  removal  should  be  pro- 
ceeded with  at  once. 

In  selecting  a  nephrectomy  or  extirpation  of  the  kidney  under 
such  states  of  disorganization,  as,  for  example,  in  pyonephrosis  com- 
plicated with  a  calculus,  the  surgeon  will  often  find  the  operation  one 
of  considerable  difficulty.  The  tissues  by  long-continuing  inflam- 
mation are  frequently  indurated  and  matted  together.  Separation 
has  to  be  effected  with  much  caution.  In  some  instances  the  cavity 
of  the  peritoneum  has  been  opened  by  reason  of  the  strong  adhesions 
that  have  formed  between  the  kidney  and  this  membrane  being  per- 
forated. Hence  the  operator,  in  determining  to  extirpate  the  kidney 
at  once,  should  be  fully  aware  of  the  obstacles  he  may  encounter. 
On  the  other  hand,  most  satisfactory  results  are  sometimes  obtained 
by  avoiding  the  great  tax  on  the  patient's  strength  that  is  entailed  by 
a  long  and  useless  suppuration,  however  perfect  the  contrivances  for 
drainage  may  be.  Then  again,  in  selecting  between  nephrotomy  and 
nephrectomy  the  possibility  of  the  drainage  resulting  in  a  lumbar 
fistula  maintained  by  the  vitality  of  a  small  portion  of  renal  gland  tis- 
sue must  not  be  overlooked.  In  a  case  of  pyonephrosis  which  I  opened 
and  drained  with  a  large  amount  of  success  and  great  comfort  to  the 
patient,  I  had  eventually  to  open  up  the  wound  and  scoop  out  what 
remained  of  renal  tissue  by  reason  of  the  great  annoyance  a  small 
urinary  fistula  entailed.  The  operation,  for  reasons  I  have  already 
referred  to,  was  extremely  difficult  and  tedious,  but  the  result  was  in 
every  way  satisfactory.  My  only  regret  was  that  I  did  not  do  this  at 
first,  when  I  opened  the  kidney  to  relieve  the  pressing  symptoms  of 
purulent  dilatation. 

I  have  thought  that  some  collections  of  matter  in  the  kidney  might 
with  advantage  be  drained  through  an  opening  in  the  perineum, 
instead  of  being  submitted  to  other  procedures,  such  as  incision  from 
the  loin,  and  even  in  some  instances  to  nephrectomy.  I  was  first 
impressed  with  this  belief  by  observing  the  relief  it  was  possible  to 
afford  to  the  ureters  and  kidneys,  which  were  undergoing  chronic 
suppuration  as  a  consequence  of  tight  stricture  in  the  urethra.  Cases 
of  this  kind,  even  complicated  by^ulceration  of  the  urethra  behind  the 
obstruction  and  extravasation  of  urine,  have  frequently  proved  so 


EENAt  CALCULUS.  137 

satisfactory  to  treat,  tliat  I  felt  the  principles  of  treatment  wliicli 
guided  us  here  might  with  equal  advantage  be  extended  to  some 
forms  of  kidney  supj)uration.  Nor  have  I  been  disappointed  in  those 
instances  where  I  had  reason  to  think  that  the  last-mentioned  condi- 
tion was  the  cause  of  the  purulent  state  of  the  bladder  for  which  the 
operation  of  perineal  urethrotomy  was  undertaken.  In  a  paper  on 
this  subject  '^  I  have  referred  to  ten  cases  of  suppurating  pyelitis  and 
ureteritis  treated  with  advantage  by  this  method.  Had  only  one 
organ  been  involved,  I  might  perhaps  have  reached  and  drained  it 
from  the  corresponding  loin.  In  one  case  where  I  opened  the  per- 
ineum and  drained  an  extensive  suppuration,  I  found  the  cause  of  it 
was  a  psoas  abscess  from  caries  of  the  vertebrae  which  had  burst  into 
the  kidney.  Though  large  quantities  of  healthy  pus  were  in  this  way 
discharged,  the  reaction  of  the  urine  remained  acid  throughout,  and 
the  patient  was  spared  much  pain  in  voiding  this  mixture  of  ims  and 
urine.  Dr.  CuUingworth  ^^  has  reported  a  case  of  renal  abscess  caused 
by  a  fragment  of  a  carious  vertebra  ulcerating  into  the  kidney  and 
forming  the  nucleus  of  a  calculus. 

In  the  after-treatment  of  operations  involving  the  kidneys  care 
must  be  taken  that  the  antiseptics  used  are  not  too  strong.  Most  of 
us  have  seen  that  condition  known  as  carboluria,  where  the  urine  is 
darkened  by  the  absorption  of  carbolic  acid.  Mr.  Edmund  Owen  " 
relates  a  case  where  nephro-lithotomy  was  followed  by  severe  saliva- 
tion after  mercuric  chloride  had  been  used  in  the  proportion  of  1  in 
1,000. 

Renal  Calculus. 

The  impaction  or  retention  of  stone  or  gravel  in  the  kidney  and  its 
surgical  treatment  will  now  be  considered.  It  will  be  necessary  to 
offer  some  remarks  as  to  the  views  that  have  been  advanced  and 
are  entertained  relative  to  the  formation  of  these  bodies,  their  varieties 
as  well  as  the  changes  they  undergo,  and  the  different  positions  they 
occupy  in  the  gland. 

Though  it  is  in  the  bladder  that  the  larger  proportion  of  calculi 
grow  and  attain  that  bulk  which  renders  them  at  present  unamenable 
to  any  other  than  surgical  treatment,  it  is  in  the  kidneys  they  for  the 
most  part  take  their  origin  and  from  whence  the  nuclei  of  these  con- 
cretions are  mainly  derived.  Apart  from  the  fact  that  many  stones 
are  jjrevented  leaving  the  kidneys,  where  they  increase  in  size  and 
reach  considerable  dimensions,  to  the  great  detriment  of  the  tissue  in 
which  they  are  lodged,  the  former  consideration  is  sufficient  to  call 
for  some  general  observations. 

Urinary  calculi  may  be  said  to  be  formed  (1)  by  the  aggregation 


138  HAERISON — DISEASES  OF  THE  KIDNEYS  AND  UEETERS. 

and  consolidation  of  certain  constituents  of  tlie  urine  whicli  it  is  tlie 
province  of  tlie  kidneys  to  eliminate — of  tliese  I  may  instance  uric 
acid,  and  oxalate  of  lime,  and  less  frequently  cystin,  carbonate  of  lime, 
and  some  rarer  substances ;  and  (2)  by  the  aggregation  of  inorganic 
particles  precipitated  from  tlie  urine  as  a  product  of  its  decomposi- 
tion. The  latter  concretion  consists  of  the  phosphate  of  lime  and 
the  ammoniaco-magnesian  phosphate.  Hence  relative  to  the  urine 
all  calculi  may  be  said  to  be  either  of  primary  or  of  secondary 
origin. 

It  is  not  within  the  province  of  this  article  to  discuss  the  physio- 
logical modes  in  which  the  constituent  particles  of  the  primary  group 
take  their  commencement,  but  it  may  be  assumed  that  in  the  process 
of  their  elimination  they  all  pass  through  the  kidney,  where  they  are 
liable  to  concrete.  So  far  as  the  secondary  group  is  concerned  it  is 
sufficient  to  say  they  are  capable  of  being  produced  wherever  it  is 
possible,  within  the  limits  of  the  apparatus,  for  the  urine  to  stagnate 
and  undergo  ammoniacal  decomposition.  Though  not  necessary  in 
the  case  of  primary  calculi,  the  presence  of  a  nucleus,  upon  which  the 
particles  may  in  the  first  instance  range  themselves,  is  essential  in  the 
secondary.  Hence  the  latter  forms  the  material  all  bodies  are  coated 
with,  which  are  foreign  to  the  urinary  apparatus,  such  as  bougies, 
catheters,  pins,  needles,  bootlaces,  feathers,  and  calculi  of  the  primary 
group,  when  they  have  remained  sufficiently  long  in  contact  with  the 
urine  to  set  up  the  amount  of  inflammation  necessary  for  the  pro- 
duction of  the  ammoniacal  decomposition  of  the  fluid.  Hence 
under  such  circumstances  the  secondary  process  of  calculus  formation 
may  be  observed,  and,  if  required,  artificially  demonstrated. 

Calculi  may  be  divided  into  three  groups :  (1)  pure  specimens  of 
primary  formations,  as  uric  acid,  or  oxalate  stones ;  (2)  specimens 
consisting  of  more  than  one  variety  of  primary  constituent,  as,  for 
instance,  a  calculus  partly  composed  of  uric  acid  and  partly  of  oxalate 
of  lime,  and  (3)  mixed  stones  or  alternating  calculi,  where  the  primary 
constituent,  we  will  say  of  oxalate  of  lime,  has  assumed  such  dimen- 
sions or  shape  as  to  excite  inflammation  in  the  part  in  contact  with 
it  sufficient  to  produce  ammoniacal  decomposition  of  the  urine ;  then 
the  stone  will  become  encased  with  a  covering  like  plaster  of  Paris 
composed  of  a  mixture  of  the  phosphate  of  lime  and  the  ammoniaco- 
magnesian  phosphate.     Practically  all  calculi  may  be  thus  grouped. 

Formation. — It  will  now  be  necessary  to  consider  the  mode  in 
which  the  minute  organic  particles  or  crystals  of  which  these  con- 
cretions mainly  consist  are  in  the  first  place  drawn  together  and  con- 
solidated into  masses  of  various  density.  To  understand  this  clearly 
is  the  keystone  to  the  prevention  of  these  formations. 


RENAL  CALCULUS.  139 

Considerable  light  has  been  thrown  on  the  subject  by  the  re- 
searches of  Rainey,  Ord,  and  Vandyke  Carter.  "  These  observations 
point  to  the  probability  of  stone  being  formed  in  the  urinary  passages 
by  the  concurrence  of  conditions  which,  though  not  necessarily  in 
themselves  morbid,  may  be  said  to  contribute  toward  the  production 
of  that  which  is  hurtful.  They  may  be  briefly  summarized  as  tending 
to  show  that  some  salts,  in  the  presence  of  a  colloid  material  such  as 
gum  or  albumin,  yield,  not  crystals,  but  certain  bodies  to  which 
Carter  has  applied  the  term  "  submorphous, "  having  the  peculiarity 
of  adhering  not  only  to  existing  surfaces,  but  also  to  each  other,  in 
laminar  series.  In  the  urine  may  constantly  be  observed  lithates 
presenting  an  appearance  similar  to  these  submorphous  forms,  and 
the  presence  of  an  organized  material  partaking  of  the  nature  of  a 
colloid  has  been  demonstrated  as  existing  in  a  large  proportion  of 
urinary  calculi.  In  reference  to  the  production  of  a  calculus  by 
molecular  coalescence,  Dr.  Vandyke  Carter  remarks:  "Regarding 
first  the  probabilities  of  the  case,  it  seems  to  me  that  the  necessary 
conditions  for  the  operation  of  molecular  coalescence  may  at  times 
occur  in  the  living  human  subject;  thus  an  excess  of  mucus,  perhaps 
altered  in  character  in  the  urinary  passages,  or  the  effusion  of  albumin, 
fibrin,  or  blood  and  the  like,  say  from  congestion  of  the  kidneys  or 
from  irritation  of  the  urinary  tract,  would  furnish  a  colloid  medium, 
with  which  uric  acid,  the  urates  or  oxalates  themselves,  perhaps  in 
excess,  could  combine  in  the  manner  before  described."  Added  to 
this  is  a  note  from  Rindfleisch  (Vol.  II.,  p.  143) :  "I  have  long  been 
in  favor  of  the  view  that  the  epithelial  cells  with  which  the  straight 
tubes  are  lined  generate  a  colloid  material  in  their  protoplasm,  which 
they  pour  out  in  the  interior  of  the  tubes." 

Carter  further  observes,  relative  to  this  process :  "  With  regard 
to  some  shell  structures,  it  will  be  sufiicient  to  remark  that  compact 
and  even  incipient  layers  often  bear  such  a  close  resemblance  to  the 
product  of  experiment  that  it  is  affirmed  the  intervention  of  cell- 
influence  is  not  needed  to  account  for  their  formation  (Rainey  and 
Harting) ;  and  some  of  these  layers  being  very  similar  in  character 
to  those  found  in  urinary  calculi,  the  inference  is  again  in  favor  of  the 
latter  originating  in  a  manner  essentially  identical. "  Analogical  evi- 
dence of  this  kind  tends,  therefore,  to  support  the  view  of  the  non- 
vital  origin  of  the  submorphous  structures  named,  notwithstanding 
their  association  with  living  organisms,  or  with  matter  once  part  of 
such. 

That  a  formative  act  such  as  is  here  referred  to  is  actually  going 
on  within  the  human  urinary  apparatus,  is  also  rendered  probable 
from  the  examination  of  stones  immediately  after  they  have  been  re- 


140  HAERISON — DISEASES  OF  THE  KIDNEYS  AJSTO  URETERS. 

moved  entire,  as  by  lithotomy.  It  will  be  found  they  are  covered  with 
a  distinct  layer  of  viscid  mucus,  which  often  adheres  with  such  tenacity 
as  to  require  washing,  with  friction,  before  it  can  be  entirely  removed. 
The  conditions  under  which  this  process  of  stone  formation  by 
molecular  coalescence  proceeds  seem  not  yet  determined.  That  there 
is  some  affinitive  attraction  between  the  various  kinds  of  inorganic 
particles  engaged  which  may  be  regulated  b}^  those  in  excess,  through 
the  medium  of  the  colloid,  is  not  improbable,  otherwise  it  would  be 
difficult  to  understand  how  grouping  takes  place  with  such  precision. 

The  view  thus  entertained  as  to  the  formation  of  calculi  by 
molecular  coalescence  through  the  intervention  of  colloid  has  had 
weight  incidentally  given  to  it  by  some  remarks  of  Mr.  Cadge  in  his 
address  before  the  British  Medical  Association,  at  the  annual  meet- 
ing at  Noi-wich  in  1874.  Beferring  to  matters  connected  with  diet, 
he  observes  that  "the  prevalence  of  stone  amongst  the  children  of 
the  poor  is  largely  due  to  their  not  obtaining  a  proper  and  suffi- 
cient supply  of  sound  milk,"  and  that  the  abundance  of  stone  in 
children  "  will  be  found  in  strict  accordance  with  the  difficulty  of 
procuring  milk."  That  is  to  say,  in  place  of  a  fluid  food  which  is 
generally  regarded  as  unirritating  to  the  urinary  organs,  others  are 
substituted  of  an  opposite  nature,  and  thus  the  urinary  mucus  is  con- 
siderably increased.  I  have  had  frequent  opportunity  for  verifying 
this  observation.  Dr.  Plowright"  more  directly  supports  the  colloid 
view,  but  from  a  somewhat  different  standpoint.  In  reference  to  the 
use  of  salt  as  an  article  of  diet,  he  observes :  "  (a)  That  the  presence 
of  salt  greatl}'  increases  the  solubility  of  uric  acid ;  (&)  that  the  con- 
sumption of  salt  by  increasing  thirst  insures  a  larger  amount  of  fluid 
passing  through  the  urinary  tract,  and  therefore  lessens  the  proba- 
bility of  calculus ;  (c)  that  by  keeping  the  colloids  equally  diffused, 
salt  tends  to  prevent  the  crystalline  solids  of  the  urine  from  agglom- 
erating into  calculi."  Dr.  Plowright  found  from  experiment  that  the 
addition  of  2  per  cent  of  salt  quadrupled  the  solubility  of  uric  acid. 

It  has  long  been  noticed,  as  Prout  remarked,  that  "  hard  waters 
have  a  great  influence  in  producing  stone."  Mr.  Cadge  also  observes 
that  "  the  balance  of  evidence  was  in  favor  of  stone  cases  being  con- 
nected with  hard  drinking-water."  In  various  neighborhoods,  I  am 
told,  the  change  from  a  hard  to  a  soft  drinking-water  by  the  substitu- 
tion of  an  artificial  supply  has  resulted  in  a  considerable  diminution 
of  stone  cases.  From  some  observations  I  have  noticed  that  corre- 
sponding variations  in  the  quality  and  quantity  of  urinary  mucus 
follow  the  drinking  of  waters  of  different  degrees  of  hardness. 

It  would  therefore  appear  probable  that  the  intercurrence  of  pro- 
vision for  the  supply  of  a  suitable  colloid  in  the  urinary  passages 


RENAL  CALCULUS.  141 

may  be  sufficient  in  itself  to  favor  the  formation  of  gravel  and 
stone  without  any  necessary  alteration  in  the  amount  of  the  urinary 
solids. 

For,  assuming  that  eight  or  ten  grains  of  so  insoluble  a  deposit  as 
lithic  acid  is  daily  excreted,"  it  seems  to  me  that  there  is  not  an  in- 
dividual in  fair  health  who  is  incapable  of  forming  a  stone  in  a 
reasonable  time,  provided  that  the  circumstances  for  concretion  are 
favorable.  If,  for  instance,  a  man  in  the  habit  of  excreting  ten  grains 
of  lithic  acid  a  day  was  only  to  void  half  this  with  his  urine,  and 
concrete  the  remainder,  it  is  obvious  he  might  form  a  stone  of  this 
material  alone,  weighing  not  less  than  half  an  ounce,  in  something 
like  forty-eight  days.  In  a  woman  the  probabilities  of  her  forming 
a  stone  are  very  considerably  less,  not  because  she  necessarily  excretes 
less  lithic  acid,  but  by  her  different  mechanism  for  urination,  not  to 
say  anything  of  the  absence  of  a  muscular  ring  or  buttress  at  the  neck 
of  the  bladder  like  the  prostate.  In  her  case  the  earlier  nuclei  of 
stone  are  tolerably  sure  to  make  their  escape  from  the  bladder,  as  it 
is  only  when  a  calculus  too  large  to  pass  through  the  urethra  descends 
from  the  kidney,  that  the  possibility  of  an  increase,  in  this  position, 
is  at  all  likely  to  occur.  The  rate  at  which  triple  phosphates  will 
concrete  in  both  sexes,  owing  mainly  to  the  rapidity  with  which  they 
are  capable  of  being  produced,  is  sometimes  very  remarkable.  Though 
lithic  acid  may  be  the  predominating  calculus  of  the  Eastern  coun- 
ties in  England,  I  do  not  see  it  asserted  that  the  urine  of  the  inhabi- 
tants contains  it  in  excess  as  compared  with  those  residing  in  other 
districts.  In  the  expression,  "  it  may  be  that  the  abundance  of  stone 
in  Norfolk  is  due  not  to  actual  excess,  but  to  circumstances  which 
merely  determine  the  precipitation  and  separation  of  lithic  acid  in 
the  urinary  tract,"  Mr.  Cadge^'  almost  offers  the  explanation  I  am 
venturing  to  lay  some  stress  upon. 

On  ground  such  as  I  have  referred  to,  I  believe  there  is  much 
practical  value  in  the  views  based  on  the  colloid  theory  relative  to  the 
formation  of  stone.  It  certainly  offers  a  reasonable  and  demonstra- 
ble explanation,  founded  on  what  appears  to  be  a  precisely  analogous 
Ijrocess,  of  the  fact  that  stones  are  usually  formed  in  the  human  body 
not  by  the  aggregation  of  salts  the  elements  of  which  are  foreign  to 
the  system,  but  by  that  of  those  which  it  is  the  natural  province  of  the 
kidneys  to  excrete  in  not  necessarily  excessive  quantities. 

The  other  process  of  concretion  differs  from  the  foregoing,  as  it  is 
dei)endent  upon  inflammation,  it  being  requisite  for  the  formation  of 
a  triple-phosi)hate  stone  that  the  inorganic  element  composing  it 
should  first  be  precii)itated  by  the  decomposition  or  a  rearrangement 
of  the  urine.    When  this  has  been  accomplished,  then  the  coalescence 


142  HARRISON — DISEASES  OP  THE  KIDNEYS  AND  URETERS. 

of  the  gritty  particles  may  be  brouglit  about  as  in  tbe  preceding 
manner. 

It  is  probable  tliat  under  sucli  circumstances  as  these,  the  crys- 
talline nuclei  of  calculi  are  collected  and  deposited  within  the  kidney 
and  increase  in  size  within  the  area  of  the  cortex,  or  in  the  more  dis- 
tinctly tubular  portion  of  the  organ.  Hence  we  have  cortical  or  some 
fixed  stones  in  contradistinction  to  these  lying  comparatively  loosely 
in  the  renal  pelvis. 

The  terms  "  gravel"  and  "  stone"  are  generally  used  to  indicate  the 
concretions  formed  within  the  urinary  apparatus.  The  former  is 
applied  to  the  smaller  varieties,  while  the  latter  denote  those  stony 
masses  which  as  a  rule  require  some  surgical  procedure  for  their  re- 
moval. There  is,  however,  no  arbitrary  limit  between  the  one  and  the 
other.  A  retained  gravel  is,  sooner  or  later,  likely  to  attain  the 
dimensions  of  a  stone. 

These  concretions  are  met  with  at  all  periods  of  life,  and  they  have 
even  been  discovered  within  the  kidneys  of  new-born  children.  I 
once  saw  a  female  infant,  only  a  few  months  old,  in  whom  a  sharp 
hsematuria  was  due  to  the  passage  of  uric  acid  crystals  of  sufficient 
size  to  be  palpable  to  the  touch.  Under  a  diet  composed  of  Con- 
trexeville  water,  milk,  and  barley  water  in  equal  proportions  the 
symptoms  and  the  gravel  entirely  disappeared. 

Physical  Characters. — Kidney  stones  vary  much  in  size,  shape, 
and  numbers.  Some  stones  are  round  like  peas  and  are  often  present 
within  the  kidneys  in  considerable  numbers,  though  their  form  ena- 
bles them  to  escape  along  the  ureters  into  the  bladder  with  tolerable 
ease.  Other  stones  are  built  up  evidently  by  an  aggregation  of  crys- 
tals. These,  as  for  instance  in  the  case  of  oxalate  of  lime,  though 
they  may  not  be  much  larger  than  those  just  referred  to,  are  exceed- 
ingly irregular  in  outline  and  are  liable  to  scratch  and  pain  the  parts 
over  which  they  are  passed  or  along  which,  as  in  the  case  of  the  ure- 
ters, they  are  extruded.  Some  renal  stones  are  of  considerable  size, 
weighing  many  ouiices,  and  are  branched  in  the  form  of  the  interior 
of  the  kidney.  Such  specimens,  by  their  growth  and  pressure,  apart 
from  the  inflammation  they  are  liable  to  excite,  eventually  bring 
about  the  disorganization  and  destruction  of  the  organ  in  which  they 
are  situated.  A  stone  in  the  kidney  is  to  all  intents  and  purposes  a 
foreign  body,  and  must  be  looked  upon  as  such. 

One  or  both  kidneys  may  be  the  habitat  of  a  calculus,  and  when, 
as  sometimes  is  the  case,  both  ureters  become  in  this  way  occluded, 
the  condition  of  the  patient  may  be  looked  upon  as  imminently  fatal 
unless  the  cause  of  the  obstruction  can  be  removed  either  without  or 
with  a  surgical  operation.     These  instances  will  again  be  referred  to. 


EENAIi -CALCULUS.  143 

The  symptoms  indicating  the  presence  of  stone  in  the  kidney  are 
various ;  they  are  seldom  all  present  in  the  history  of  any  given  case, 
and  they  are  liable  to  be  modified,  or  to  remain  in  abeyance,  by  cir- 
cumstances which  are  determined  by  the  position  the  calculus  occu- 
pies in  the  gland  or  its  outlet.  The  most  common  symptom  is  that 
of  pain,  which  may  be  either  direct  or  reflected.  By  direct  pain  is 
meant  that  which  is  more  or  less  constantly  complained  of  in  the 
region  of  the  kidney.  It  is,  as  a  rule,  aggravated  by  movement  of  the 
body.  In  many  cases,  though  there  is  some  degree  of  pain  or  uneasi- 
ness when  the  patient  is  at  rest,  it  becomes  intense  on  his  engaging 
in  work  which  necessitates  movements  of  the  body.  On  this  ground 
alone  I  have  operated  on  several  occasions  with  success  though  all 
other  symptoms  of  renal  calculus  were  absent.  In  the  case  of  a  cor- 
tical stone  this,  in  fact,  may  be  the  only  symptom.  The  pain  is 
usually  increased  by  pressure  over  the  kidney  or  when  the  loin  is 
grasped  with  the  hand.  Then  there  is  the  violent  paroxysmal  pain 
know  as  kidney  colic,  when  a  stone  is  on  the  move  and  is  making  its 
way  down  the  ureter  toward  and  into  the  bladder.  Probably  this 
represents  the  most  unbearable  form  of  suffering,  and  as  a  rule  calls 
for  the  use  of  an  anodyne.  These  paroxysms  are  often  accompanied 
by  rigors,  vomiting,  cramp,  and  profuse  perspiration.  There  is 
usually  a  frequent  desire  to  pass  water.  Then  we  have  the  reflected 
pains ;  of  these,  the  most  common  are  those  down  the  groin  and  in  the 
testicle,  the  gluteal  region,  and  along  the  inner  side  of  the  thigh  and 
leg.  The  former  are  often  accompanied  with  more  or  less  retraction  or 
drawing  up  of  the  testicle.  The  paroxysm  of  intense  pain  often  termi- 
nates abruptly,  and  the  patient  is  at  the  same  time  not  unfrequently 
conscious  that  something  has  suddenly  dropped  from  the  ureter  into 
the  bladder.  Later  on  he  may  also  be  aware  that  the  calculus  has 
escaped  from  the  bladder,  being  voided  in  the  act  of  micturition. 

I  have  met  with  several  instances  of  individuals  with  some  per- 
sonal experience  of  this  disorder  who  have  felt  quite  sure  that  the 
stone  had  not  left  the  bladder,  being  too  large  to  escape  by  the  ure- 
thra. This  has  led  to  the  introduction  of  a  lithotrite  without  waiting 
for  the  stone  to  increase  in  this  position,  and  the  immediate  crushing 
of  the  calculus  and  its  evacuation.  Thus  a  slight  and  safe  operation 
is  substituted  for  one  when  by  the  size  of  the  stone  the  difficulty  and 
risk  are  proportionately  increased.  Because  a  patient  is  not  con- 
scious of  spontaneously  voiding  stone  during  micturition  and  obtain- 
ing evidence  of  it,  this  by  no  means  implies  that  he  has  not  done  so. 
Most  stones  of  recent  descent  from  the  kidneys  are,  I  believe,  usually 
voided  during  defsecation,  when  the  expulsive  acts  are  as  a  rule  most 
advantageously  performed. 


144  HAEEISON — DISEASES   OF  THE   KIDNEYS  AND  UEETEES. 

Hsematuria,  or  tlie  passing  of  blood  witli  the  urine,  is  a  frequent 
sign  of  calculus  in  tlie  kidney,  as  it  is  also  when  the  stone  is  in  the 
bladder.  In  the  former  case  it  is  variable  in  amount  and  is  due  to 
the  scratching  of  the  soft  parts  by  the  movement  of  the  calculus.  I 
have  known  it  profuse  in  a  case  where  a  calculus  was  accidentally 
dislodged  from  its  position  within  the  kidney  by  a  severe  fall.  Some 
days  after  this  occurred  I  cut  down  on  the  kidney  and  removed  from 
the  cortex  an  oxalate  stone  which,  though  not  large,  was  much  spiked ; 
the  hemorrhage  ceased  in  the  course  of  a  few  days  and  the  patient 
made  a  good  recovery.  Of  course,  where  there  is  blood,  albumin  in 
a  corresx)onding  proportion  will  be  found  in  the  urine.  Instances 
are,  however,  met  with  where  the  irritation  of  a  stone  causes  albumi- 
nuria independently  of  hemorrhage,  as  I  have  known  it  to  entirely  dis- 
appear after  the  removal  or  spontaneous  escape  of  the  foreign  body. 
It  must  not  be  forgotten  that  in  recurring  attacks  of  renal  colic  the 
symptoms  may  be  much  modified  by  reason  of  the  comparative  ease 
with  which  calculi  move  along  parts  dilated  by  previous  attacks  of 
this  kind. 

The  j)resence  of  pus  in  the  urine  is  frequently  seen  in  connection 
with  a  renal  calculus,  and  when  taken  together  with  other  symptoms 
is  evidence  that  inflammatory  changes  are  in  existence  which  may 
terminate  in  the  disorganization  of  the  organ.  It  is  a  symptom,  in 
conjunction  \\dth  attacks  of  renal  colic,  of  grave  importance. 

In  the  early  stages  connected  with  the  impaction  or  rather  reten- 
tion of  gravel  within  the  kidneys,  a  very  considerable  increase  in  the 
amount  of  mucus  in  the  urine  may  be  observed.  It  is  not  uncom- 
mon to  find  in  cases  of  this  kind,  on  placing  the  excretion  in  a  urine 
glass  and  letting  it  stand  for  some  time,  that  though  blood  and  pus 
may  be  absent  the  amount  of  mucus  is  often  doubled  or  even  trebled, 
while  its  density  is  increased.  This  is  a  symptom  of  considerable 
importance,  especially  in  young  persons  who  are  not  likely  to  have  any 
prostatic  enlargement.  Sufficient  stress  is  not  always  placed  upon 
this  point. 

As  Sir  William  Roberts  has  pointed  out,  renal  stones  may  some- 
times be  latent  and  quiescent  so  far  as  all  symptoms  are  concerned. 
This  author  remarks :  "  Kenal  symptoms  may  exist  for  a  longer  or 
shorter  period,  and  then  wholly  and  finally  cease.  This  latter  event 
may  occur  under  two  circumstances ;  either  the  concretion  completely 
occludes  the  ureter,  and  determines  gradual  atrophy  of  the  kidney,  or 
it  becomes  encysted  in  a  lateral  pouch  or  diverticulum  and  ceases  to 
impede  the  flow  of  urine  and  to  irritate  the  mucous  membrane." 

The  diagnosis  of  renal  calculi  is  not  usually  attended  with  much 
difficulty,  though  in  the  case  of  cortical  stones,  as  already  remarked, 


renal' CALCULUS.  145 

the  symptoms  are  not  always  well  pronounced.  As  with  the  bladder, 
stationary  stones  do  not  so  readily  declare  themselves  as  those  that 
alter  their  position  somewhat  in  accordance  with  the  movements  of 
the  body.  The  diagnosis  of  renal  calculus  has  in  some  instances  been 
aided  by  the  surgeon  recognizing  from  the  loin  on  manipulation  a 
characteristic  grating  when  more  than  one  calculus  was  present. 

Suppression  of  urine  is  occasionally  met  with  as  a  consequence  of 
the  presence  of  calculus  affecting  both  kidneys,  or  when  only  one  kid- 
ney exists.  There  is  a  case  recorded  by  Dr.  D.  Newman  where 
death  followed  suppression  of  urine  which  had  existed  for  five  days. 
At  an  autopsy,  symmetrical  blocking  of  both  ureters  with  calculi  was 
found.  Mr.  Godlee  records  a  case  where  large  calculi  were  removed 
from  both  kidneys  in  successive  operations,  and  Mr.  Lucas  cites  an 
instance  where  nephro-lithotomy  (following  nephrectomy)  for  total 
suppression  of  urine  was  permanently  successful. 

The  conditions  which  may  in  some  degree  resemble  renal  calculus 
are  the  periodical  discharge  of  large  quantities  of  crystalline  material 
down  the  urinary  apparatus  as  we  see  in  certain  gouty  subjects,  as 
well  as  the  subacute  symptoms  which  sometimes  arise  in  connection 
with  the  passage  of  organized  substances  from  the  kidney  downward, 
as  occurs  in  cases  of  tubercular  and  cystic  kidney  and  in  hydatids  of 
this  organ.  A  storm  of  uric  acid  crystals,  for  instance,  in  their  tran- 
sit downward  from  the  kidney  may  cause  symptoms  closely  re- 
sembling those  of  renal  colic.  There  is  local  pain  and  spasm,  aching 
down  the  thighs  or  sensations  in  the  testicles,  not  much  less  severe 
than  when  a  stone  in  passing,  and  occasionally  the  urine  is  tinged 
with  blood.  It  is  a  form  of  gout  which  generally  ends  in  this  way 
when  the  symptoms  gradually  subside.  Oxalate  of  lime  crystals  in 
some  dyspeptic  subjects  may  produce  similar  effects.  The  micro- 
scope serves  to  provide  the  means  of  making  the  diagnosis  in  these 
instances. 

The  debris  caused  by  the  disintegration  of  tubercular  abscesses 
and  its  escape  down  the  ureters  will  sometimes  provoke  much  renal 
colic,  in  the  same  way  that  the  colloid  contents  of  cysts  opening  into 
the  kidneys  will  do.  These  conditions,  however,  are  not  very  likely 
to  be  mistaken  for  those  of  renal  calculus,  though  they  may  be  the 
cause  of  very  considerable  intermittent  pain. 

I  have  recently  seen  a  case  in  which  a  woman  for  a  long  period  was 

supposed  to  suffer  periodically  from  the  colic  of  kidney  stone,  and  the 

attack  certainly  had  a  close  resemblance  to  the  latter,  judging  from 

the   descrijjtion   that  was    given.     This   conclusion  was   somewhat 

strengthened  by  the  fact  that  I  had  removed  a  uric  acid  calculus  from 

the  bladder  of  her  father  by  crushing.    However,  when  the  urine  came 
Vol.  I. -10 


146  HAEEISON — DISEASES  OP  THE   KIDNEYS  AKD  UKETEES. 

to  be  examined  tlie  presence  of  hydatids  was  readily  discovered  in 
tlie  excretion,  wliicli  observation  was  corroborated  by  a  physical  ex- 
amination of  the  loin.  Hence  in  all  instances  where  there  is  pain 
such  as  we  get  with  the  movement  of  calculi  in  the  kidney,  the  urine 
should  be  carefully  tested,  and  examined  with  the  microscope,  before 
a  conclusion  is  arrived  at. 

The  treatment  of  renal  calculus  may  be  considered  under  the  three 
headings  which  the  subject  naturally  presents:  (1)  Preventive; 
(2)  Medicinal;  and  (3)  Surgical.  It  is  the  last  section  that  more 
strictly  comes  within  the  limits  of  this  article. 

It  may,  however,  be  said  before  proceeding  to  an  operation  for  the 
removal  of  stone  from  a  kidney  the  surgeon  will  probably  satisfy  him- 
self that  such  expedients  as  massage  and  the  shampooing  of  the 
affected  side  in  conjunction  with  the  flushing  of  the  urinary  apparatus 
from  within,  as,  for  instance,  by  the  drinking  freely  of  bland  fluids  such 
as  pure  water  or  barley  water,  or  of  medicinal  waters  as  those  of 
Contrexeville,  Ems,  and  other  spas  that  might  be  mentioned,  are  of 
no  avail.  If  in  spite  of  these  attentions  the  symptoms  of  renal  cal- 
culus remain  unrelieved,  the  protracted  as  well  as  the  prospective 
suffering  of  the  patient  will  demand  the  mechanical  removal  of  the 
foreign  body  before  the  time  has  arrived  when  structural  deteriora- 
tion of  the  organ  commences. 

It  will  be  convenient  to  describe  in  this  section  the  two  operations 
which  a  calculus  within  the  kidney  may  entail.  These  are  nephro- 
lithotomy, or  the  removal  of  a  stone  from  within  the  limits  of  the  kid- 
ney, and  nephrectomy,  or  the  extirjjation  of  the  organ  when,  by  reason 
of  the  continued  presence  of  a  stone,  the  kidney  has  been  so  destroyed 
as  to  be  not  only  beyond  the  reach  of  repair,  but  as  harmful  to  the 
body  generally  as  a  disintegrated  joint  urgently  requiring  removal 
or  amputation  of  the  limb. 

As  it  is  not  always  possible  to  be  absolutely  certain  of  the  exis- 
tence of  a  calculus  within  the  kidney,  especially  in  those  cases  where 
for  some  reason  or  other,  as  for  instance  the  fixation  of  a  stone,  the 
leading  symptoms  are  in  abeyance,  the  operation  of  nephro-lithotomy 
becomes  dependent  upon  what  exploration  of  the  part  with  the  finger 
reveals.  Digital  exploration  of  the  susi^ected  organ  is  a  method  free 
from  risk  and  a  necessary  preliminary  to,  as  well  as  part  of,  what 
will  have  to  be  done  if  a  stone  is  discovered.  It  will  be  understood 
that  my  remarks  now  are  entirely  confined  to  the  lumbar  proceedings. 
To  expose  a  kidney  with  the  view  of  exploring  it  both  by  sight  and 
touch,  or  for  the  purposes  of  nephrotomy,  nephro-lithotomy,  or  ne- 
phrectomy, an  opening  in  the  loin  is  required.  Such  an  incision  is  to 
be  selected  as  is  capable  of  adaptation  for  the  several  procedures 


EENAL  CALCULUS.  147 

mentioned,  should  exploration  prove  tlie  necessity  for  adopting  further 
measures. 

A  vertical  or  a  transverse  incision  is  usually  selected,  or  a  com- 
bination of  the  two.  The  vertical  incision  may  be  made  along  the 
outer  border  of  the  erector  spinse  from  the  lowest  rib  to  the  crest  of 
the  ilium.  If  the  transverse  opening  is  preferred  a  line  should  be 
taken,  to  the  extent  of  about  three  or  four  inches,  corresponding  in 
location  with  that  for  a  lumbar  colotomy,  though  somewhat  closer  to 
the  rib  than  in  the  latter  case.  The  vertical  incision  as  described, 
with  a  transverse  extension  forward  to  the  length  of  about  three 
inches,  will  in  most  subjects  be  found  convenient  as  giving  the  great- 
est amount  of  room  for  manipulation  in  every  direction. 

The  subsequent  stages  consist  in  the  division  of  the  layers  of 
muscle  and  fascia  until  the  perirenal  fat  is  exposed,  which  is  readily 
distinguishable.  There  is  seldom  much  bleeding,  and  the  steps  of 
the  operation  will  be  greatly  facilitated  by  the  use  of  suitable  retrac- 
tors. As  the  kidney  is  approached,  firm  pressure  from  the  front,  by 
the  hand  of  an  assistant,  assists  the  operator  in  recognizing  it  with 
the  finger.  The  surface  of  the  kidney  should  then  be  carefully  ex- 
plored by  the  finger  both  in  front  and  behind  as  far  as  it  is  possible 
to  do  so  without  unnecessarily  loosening  its  connections.  In  this  way 
the  operator  will  soon  learn  to  recognize  inequalities  in  surface  and 
textural  differences  which  indicate  stone,  fluid,  new  growth,  or  an 
undue  mobility  of  the  organ.  If  the  finger  is  not  sufficient  for  this 
purpose  the  kidney  may  be  punctured  in  one  or  more  places  with  a 
fine  trocar,  and  thus  the  presence  of  stone,  for  instance,  or  fluid,  as 
in  the  case  of  a  cyst  or  a  suppuration  which  otherwise  might  escape 
notice,  may  be  ascertained.  The  information  so  obtained,  either 
negative  or  positive,  will  determine  what  is  best  to  be  done. 

In  this  way  nephrotomy  or  the  free  opening  of  the  kidney  may  be 
practised,  for  the  introduction  of  a  drainage-tube  in  suppurative 
conditions  involving  the  interior  of  the  organ  as  previously  men- 
tioned. Where  the  kidney  is  opened  along  its  free  border  for  drain- 
age as  is  usually  the  case,  the  sides  of  the  wound  may  be  anchored 
by  silk  or  catgut  sutures  to  corresponding  positions  in  the  superficial 
incision,  so  that  there  may  be  no  obstacle  to  the  escape  of  matter, 
though  the  mere  insertion  of  the  end  of  the  drainage-tube  within  the 
kidney  opening  generally  suffices.  Any  hemorrhage  may  be  arrested 
by  packing  antiseptic  gauze  round  the  tube. 

Assuming,  for  instance,  that  these  methods  of  exploration  fail  in 
determining  the  presence  of  a  stone,  it  is  not  to  be  concluded  that  no 
good  will  come  out  of  the  proceeding.  In  several  cases  where  I  have 
explored  for  pain  no  stone  was  found,  but  complete  recovery  fol- 


148  HAEEISON — DISEASES  OF  THE  KIDNEYS  AND  URETERS. 

lowed.  I  am  disposed  to  think  in  some  instances  tension  lias  been 
relieved  and  pain  permanently  alleviated  by  tlie  opening  of  the  cap- 
sule of  the  kidney  for  the  purposes  of  puncture  or  further  explora- 
tion, as  sometimes  happens  in  the  case  of  the  testes  when  inflamed. 
I  have  never  seen  any  harm  arise  from  direct  lumbar  examination  of 
the  kidney,  and  I  can  hardly  recall  an  instance  where  permanent 
benefit  did  not  follow.  Some  of  these  cases  of  recovery  were  explain- 
able by  a  more  absolute  fixation  of  the  organ  following  upon  the  pro- 
cedure. Where  the  kidney  has  not  been  opened  or  is  only  punctured 
the  wound  in  the  skin  may,  if  desired,  be  immediately  closed  by 
sutures. 

I  will  now  take  the  case  where  either  by  the  finger  or  the  exploring 
trocar  direct  and  unmistakable  evidence  is  afforded  of  the  presence  of 
a  stone.  Our  course  of  action  will  be  influenced  to  a  large  extent  by 
the  position  the  calculus  occupies  in  the  kidney,  and  its  size. 

The  last  two  cases  of  renal  calculus  I  operated  upon  presented 
varieties  which  will  conveniently  serve  to  illustrate  this  point.  The 
first  case  was  that  of  a  man  who  for  many  years  had  a  fixed  pain  in  his 
kidney  without,  I  may  say,  any  other  symptom.  I  hardly  expected 
to  find  a  stone,  yet  on  reaching  the  kidney  my  finger  felt  one  about 
the  size  of  a  filbert  situated  in  that  part  of  the  cortex  which  naturally 
would  first  come  within  m.j  reach.  With  a  few  scratches  of  my  nail 
I  was  able  to  expose  the  calculus  and  then  to  remove  it  with  a  pair 
of  forceps.  A  drainage-tube  was  introduced  and  the  wound  was 
closed  around  it  with  superficial  sutures.  Recovery  was  complete  in 
ten  days.  In  the  second  case  the  symptoms  of  renal  calculus  were 
much  more  pronounced,  the  patient  frequently  suffering  from  acute 
attacks  of  lumbar  colic  but  with  no  hsematuria.  In  a  similar  way  I 
explored  the  kidney,  and  in  front  of  the  organ,  just  at  the  junction  of 
the  pelvis  and  hardly  within  reach  of  my  finger,  I  felt  a  stone,  but 
without  drawing  the  kidney  out  of  the  wound  for  the  purpose  of  ex- 
amination, a  step  which  I  do  not  prefer,  it  was  impossible  for  me  to 
expose  the  foreign  body  in  this  position.  Even  if  I  had  been  able  I 
should  not  have  removed  it  in  this  way,  as  by  scratching  through  the 
anterior  surface  of  the  organ  so  near  to  the  pelvis  I  should  have  left 
an  opening  which  would  certainly  have  resulted  in  a  renal  fistula. 
Under  these  circumstances  I  entered  the  organ  by  an  incision  along 
the  convexity,  which  was  easily  within  reach,  and  passed  my  finger 
into  the  dilated  calyces  from  which  two  stones  were  speedily  removed 
by  forceps.  A  drainage-tube  was  introduced  down  to  the  surface  of 
the  opening  in  the  kidney,  and  then  the  superficial  incision  was  drawn 
together  by  sutures  around  it.  The  patient  rapidly  recovered  without, 
as  far  as  I  could  ascertain,  any  urine  escaping  except  by  the  urethra. 


EENAI,' CALCULUS.  149 

By  thus  reaching  the  stone,  after  its  position  had  first  been  defined 
by  examination  of  the  surface  of  the  organ  with  the  finger,  its  removal 
was  rapidly  efi^ected  without  any  unnecessary  laceration,  and  by  means 
of  such  an  opening  for  the  withdrawal  of  the  calculus  as  would  not  be 
likely  to  fail  in  healing  rapidly  and  completely.  These  two  different 
proceedings  thus  illustrated  represent,  I  believe,  important  principles 
in  the  operative  treatment  of  renal  calculus. 

Where  exploration  shows  that  the  stone  is  very  large  and  branched, 
as  is  often  the  case,  it  is  desirable  to  extend  somewhat,  by  means  of  a 
probe-pointed  bistoury,  the  incisions  referred  to.  In  some  instances 
it  has,  I  believe,  been  found  necessary  to  divide  the  lowest  rib  where 
the  lumbar  space  is  preternaturally  small.  This,  however,  is  not  to 
be  recommended  if  it  is  possible  to  avoid  it,  as  it  adds  considerably 
to  the  risk  of  the  operation  and  endangers  the  pleura.  It  is  occasion- 
ally necessary  to  break  up  a  stone  with  a  pair  of  forceps  before  at- 
tempting its  removal.  This  may  be  the  case  in  some  of  those  stones 
which  appear  to  be  moulded  within  the  expanded  calyces.  When  there 
is  evidence  from  exploration  that  the  kidney  has  been  so  destroyed 
by  the  presence  of  the  foreign  body  as  to  be  beyond  reasonable 
chance  of  speedy  repair,  it  is  best  to  proceed  at  once  with  the  extirpa- 
tion of  the  organ.  To  leave  the  mere  remnants  of  a  suppurating  gland 
with  its  fibrous  investment  more  or  less  thickened  by  a  long  process 
of  inflammation,  is  sure  to  result  in  the  formation  of  a  troublesome 
sinus  and  the  prospect  of  another  operation. 

Nephrectomy,  or  the  complete  removal  of  a  kidney,  is  an  operation 
which  may  be  required  for  various  conditions  already  incidentally  re- 
ferred to.  Though,  as  a  rule,  we  are  provided  with  two  kidneys,  it 
should  not  be  forgotten  that  examples  occasionally  occur  where  this 
is  not  the  case  and  where  the  necessary  amount  of  gland  tissue  requi- 
site for  the  excretion  of  the  urine  is  consolidated  in  one  mass,  some- 
what variously  disposed  so  far  as  shape  is  concerned.  Instances  are 
recorded,  but  very  rarely,  where  the  operator  has  discovered,  when 
too  late,  that  the  kidney  removed,  though  hopelessly  diseased,  was 
the  only  one.  It  is,  therefore,  of  the  first  importance  before  proceed- 
ing to  remove  a  kidney  for  the  surgeon  to  satisfy  himself  by  all  avail- 
able means  that  the  opposite  organ  not  only  is  in  existence,  but  is  in 
sufficient  health  to  be  able  to  provide  for  the  entire  urinary  excre- 
tion; that,  in  fact,  it  is  capable  of  undergoing  those  hypertrophic 
changes  requisite  for  the  attainment  of  this  end. 

Assuming  in  a  given  case  that  there  is  evidence  that  one  kidney  is 
seriously  crif>i)led  by  one  or  other  of  the  various  conditions  already 
referred  to,  the  surgeon  will  not  neglect  by  frequent  examinations  of 
the  urine  to  ascertain  that  in  regard  to  both  its  quantity  and  quality 


150  HABEISON — DISEASES  OF  THE  KIDNEYS  AND  URETEES. 

a  fair  standard  is  maintained.  Tlie  amount  of  urea  voided  should  be 
carefully  estimated.  The  result  of  such,  an  examination  of  the  urine 
might  lead,  if  the  symptoms  were  not  pressing,  to  some  temporary 
postponement  of  the  operation  of  nephrectomy,  with  the  view  of  giving 
the  sound  organ  a  little  more  time  for  adaptation.  With  the  same 
object  the  practitioner  will  not  neglect,  in  prospect  of  extirpating  a 
kidney,  to  ascertain  by  an  inspection  of  the  interior  of  the  bladder 
with  the  electric  light,  or  perhaps  even  by  more  direct  means  in  a 
very  doubtful  case,  whether  both  ureters  are  in  action.  The  cysto- 
scope  is  often  a  most  valuable  and  practical  means  of  diagnosis  under 
these  circumstances,  which  I  consider  should  never  be  neglected  in 
cases  of  this  kind.  Not  only  in  this  way  can  the  pumping  action  of, 
and  flow  from,  the  ureters  be,  as  a  rule,  seen,  but  the  different  char- 
acter of  the  two  urines  discharging  from  these  ducts,  as  for  instance 
when  one  is  puiiilent  or  tinged  with  blood,  as  compared  with  the 
normal  flow  from  the  opposite  one,  may  be  recognized. 

The  operation  of  catheterizing  the  ureters  in  the  female  is  thus 
referred  to  in  a  case  published  by  Mr.  H.  E.  Clark  :^'  "  To  settle  our 
doubts  as  to  the  soundness  of  the  right  kidney  we  again  catheterized 
the  ureters.  This  was  done  by  Dr.  Macintyre  and  myseK  by  means 
of  Pawlik's  catheter.'  The  operation  is  in  the  female  a  very  simple 
one,  two  ridges  felt  on  the  anterior  wall  of  the  vagina  serving  as  use- 
ful and  reliable  guides,  which  lead  the  catheter  directly  to  the  ure- 
teral orifices.  The  small  quantity  of  urine  removed  from  the  right 
ureter  was  in  every  respect  normal ;  that  from  the  left  contained  pus, 
epithelial  debris,  and  a  trace  of  albumin." 

It  has  been  urged  in  favor  of  abdominal  nephrectomy  that  the 
operator  is  not  likely  to  be  exposed  to  the  risk  of  removing  a  solitary 
kidney  by  reason  of  his  being  able  to  ascertain  beyond  all  doubt  that 
this  is  not  the  case. 

The  lumbar  operation  consists  in  exposing  the  kidney  by  incision 
through  the  loin  as  already  described.  Sufficient  room  should  be 
provided  for  manipulating  the  part  to  be  removed  by  the  extension  of 
the  transverse  portion  of  the  opening  to  about  four  inches  in  length. 
The  surface  of  the  organ  having  been  recognized  the  operator  should 
proceed  to  free  it,  mainly  with  the  index  finger,  from  surrounding 
connections.  Care  will  be  required  in  detaching  it  in  front  not  to 
exercise  too  great  force  for  fear  of  opening  the  peritoneal  cavity. 
When  the  kidney  has  thus  been  isolated  with  the  exception  of  its 
pelvic  attachments,  it  should  be  gradually  drawn  through  the  wound, 
when  the  parts  constituting  the  pedicle  may  sometimes  be  more 
clearly  defined  by  the  use  of  a  blunt  dissector.  The  pedicle  is  best 
secured  by  passing  an  aneurism  needle  armed  with  a  long,  stout  silk 


KENAli'CALCULUS.  151 

ligature  between  tlie  ureter  and  vessels.  If,  as  tlie  needle  is  with- 
drawn, the  ligature  is  divided  in  tlie  middle,  a  noose  will  be  provided 
for  each  of  the  two  portions  now  forming  the  pedicle.  As  they  are 
tightened  the  ligatures  should  be  pressed  well  backward  so  as  to  give 
sufficient  room  for  the  removal  of  the  kidney  by  division  of  the  pedicle 
with  the  scissors.  Morris  mentions  that  the  process  of  drawing  out 
the  kidney  may  be  much  facilitated  by  pulling  the  lower  ribs  up- 
ward with  the  fingers  of  the  left  hand  passed  into  the  incision.  The 
ligatures  should  be  cut  off  short  and  the  pedicle  dropped  into  the 
wound ;  when  there  is  difficulty  in  restraining  hemorrhage  by  ligatures, 
the  bleeding  points  may  be  secured  by  pressure-forceps,  which  can  be 
left  in  the  wound  where  they  will  temporarily  serve  the  purpose  of 
drainage-tubes.  In  case  this  is  not  necessary  a  good-sized  rubber 
tube  should  be  passed  to  the  bottom  of  the  wound,  when  the  superficial 
incision  may  be  adjusted  with  sutures.  If  in  the  course  of  the  oper- 
ation the  peritoneum  is  opened,  the  rent  should  be-  carefully  closed 
with  catgut  sutures.  The  position  of  the  patient  in  the  after-treat- 
ment is  entremely  favorable  for  repair,  and  it  is  remarkable  with  what 
rapidity  these  wounds  frequently  heal. 

Abdominal  nephrectomy  has  been  practised  with  success,  but  the 
lumbar  method  is  the  more  generally  accepted  operation.  The 
former  is  now  probably  limited  to  some  exceptional  cases  of  floating 
kidney,  where  there  are  grounds  for  believing  from  the  movements  of 
the  organ  that  there  is  a  very  complete  mesonephron,  and  to  some 
instances  of  renal  tumor.  The  method  of  proceeding  usually  adopted 
is  that  of  Langenbuch,"  where  the  abdomen  is  opened  along  the  outer 
border  of  the  rectus  corresponding  with  the  kidney  which  is  prob- 
ably involved.  This  plan  is  adopted  by  Mr,  Knowsley  Thornton,^* 
who  certainly  favors  the  selection  of  this  route.  After  the  opposite 
kidney  and  ureter  have  been  examined  by  passing  the  hand  into  the 
peritoneal  cavity,  a  flat  sterilized  sponge  is  introduced  to  protect  the 
intestines.  The  kidney  is  reached  by  opening  the  outer  layer  of  the 
mesocolon,  and  is  then  enucleated.  The  vessels  are  tied  either  sepa- 
rately or  in  a  mass,  and  the  ureter  is  dealt  with  independently.  Mr. 
Thornton  thus  describes  his  method  of  dealing  with  the  latter :  "  Its 
renal  end  should  be  secured  by  pressure-forceps,  then  a  ligature  tied 
a  little  way  from  the  forceps,  and  a  sponge  placed  under  it  before  it 
is  divided.  Whenever  it  is  possible,  I  enucleate  it  for  some  distance 
from  the  kidney  before  dividing  it,  so  that  its  cut  end,  with  the 
sponge  under  it,  may  be  at  once  drawn  outside  the  abdomen ;  and  I 
afterward  fix  it  in  the  lower  angle,  or  most  convenient  part  of  the 
abdominal  incision,  with  a  cleansed  safety-pin.  I  regard  this  fixing 
out  of  the  stump  of  the  ureter  as  the  most  important  detail  in  the 


152  HAREiSON — DISEASES  OP  THE  KIDNEYS  AND  UEETERS. 

operation,  and  in  every  case  in  wliicli  I  have  been  obliged  to  cut  it  off 
deep  in  the  wound,  I  have  had  distinct  evidence  of  suppuration  and 
trouble  round  it."  All  vessels  having  been  secured  and  the  wound 
thoroughly  cleansed,  a  Keith's  glass  drainage-tube  may  be  introduced 
if  there  is  any  doubt  as  to  the  asepticity  of  the  operation.  Thornton 
does  not  consider  there  is  any  necessity  to  suture  the  edges  of  the  sac 
from  which  the  kidney  has  been  withdrawn.  The  abdominal  wound 
is  finally  closed  in  the  usual  way  as  after  ovariotomy.  Mr.  Thorn- 
ton also  describes  a  method  of  removing  renal  calculi  by  combining 
the  abdominal  and  lumbar  incisions,  exploring  the  kidneys  by  the 
former  and  then  extracting  the  stone  by  the  latter.  The  after-treat- 
ment of  cases  of  nephrectomy,  whichever  route  is  selected,  will  be 
conducted  with  due  regard  to  antiseptic  principles,  care  being  taken 
to  secure  the  most  perfect  drainage  of  the  wound.  The  use  of  opium 
is  not  to  be  recommended,  as  instances  are  recorded  where  there 
could  be  no  doubt  that  even  small  doses  interfered  with  the  excretory 
action  of  the  remaining  organ. 

I  have  endeavored  to  indicate  in  somewhat  broad  terms  the  condi- 
tions which  would  seem  to  determine  the  selection  of  the  lumbar  or 
the  abdominal  method.  In  a  doubtful  case  I  have  no  hesitation  in 
stating  that  I  would  prefer  the  former  mainly  on  the  grounds  that  it 
is  the  safer  operation.  Its  technique  is,  as  a  rule,  not  difficult,  and  the 
fact  that  the  operator  is  behind  the  peritoneum  and  not  within  its 
cavity,  as  it  is  called,  is  a  point  which  in  the  septic  varieties  of  the 
conditions  demanding  the  removal  of  the  kidney  is  of  no  little  impor- 
tance. Then  again,  as  already  stated,  when  the  operation  is  success- 
fully over,  no  form  of  wound  heals  more  kindly  than  these,  for  the 
reason  that  they  are  so  easily  drained.  Only  a  few  years  ago,  and 
not  without  reason,  considerable  stress  was  laid  on  the  fact  that  by 
the  abdominal  method  such  a  calamity  in  surgery  as  the  removing  of 
a  patient's  solitary  kidney  could  not  possibly  occur.  The  force  of  this 
objection  has  been  met  by  the  character  of  the  information  that  is 
now  indisputably  obtained  by  electric  endoscopy.  This  instrument 
is  no  longer  a  chimera,  and  its  use  will  relieve  the  surgeon  of  all 
apprehension  when  proceeding  to  perform  a  nephrectomy  that  the 
organ  he  is  about  to  remove,  though  seriously  and  permanently  crip- 
pled, should,  by  reason  of  the  absence  of  its  fellow,  be  regarded 
somewhat  in  the  light  of  an  unreliable  pensioner  whose  services  he 
is  forced  to  retain. 

Renal  Tuberculosis. 

Some  observations  will  now  be  offered  in  reference  to  the  surgical 
aspect  of  tubercular  or  scrofulous  kidney  in  addition  to  what  is  in- 


RENAL  TUBERCULOSIS.  153 

eluded  under  the  sections  devoted  to  nepliritic  suppurations  and  pyo- 
nephrosis. The  deposition  of  tubercles  in  the  kidney,  its  pelvis,  or 
its  ureter  is  a  frequent  cause  of  the  latter  conditions,  and  cannot  as 
a  rule  be  dissociated  from  them.  Hence  some  general  remarks  on 
the  subject  of  urinary  tuberculosis  will  be  necessary. 

Tubercular  disease  of  the  genito-urinary  organs  has  much  in  com- 
mon with  what  is  observed  when  it  attacks  other  parts  of  the  body. 
In  the  first  place  it  is  distinctly  hereditary,  and  we  usually  find  that 
a  patient's  predecessors  suffered  from  some  form  of  tubercular  dis- 
ease. The  family  history,  therefore,  is  an  important  investigation, 
and  should  be  carefully  gone  into  when  there  are  grounds  for  believ- 
ing that  the  disorder  may  be  of  this  nature. 

Secondly,  the  disease  corresponds  in  its  occurrence  with  that 
period  of  life  when  the  development  and  use  of  the  sexual  organs  are 
commencing  and  continuing  to  be  active ;  it  is  essentially  a  disease  of 
adolescence  and  of  vigorous  though  not  necessarily  robust  manhood. 
It  is  comparatively  rare  in  women.  When  tubercle  attacks  females 
the  most  frequent  seat  is  the  lungs,  and  why  their  sexual  apparatus 
enjoys  this  comparative  immunity  is  not  at  first  sight  so  apparent. 
It  may  be,  and  certainly  is  to  some  extent,  due  to  the  fact  that  females 
are  less  exposed  than  males  to  what  I  may  term  the  excitants,  or  per- 
haps more  correctly  the  localizers,  of  this  disorder.  In  tubercular 
subjects,  protracted  gonorrhoea  and  its  complications,  more  frequently 
than  all  other  causes  put  together,  determine  the  deposit  in  some 
region  of  the  urinary  tract,  from  which  it  slowly  spreads  to  other 
parts  of  the  system.  A  chronic  orchitis  is  a  constant  precursor  of 
urinary  phthisis.  Women,  though  they  suffer  from  gonorrhoea,  do 
not  do  so  in  the  same  way  or  to  the  same  degree,  nor  are  their  com- 
plications of  the  disorder  so  protracted  or  severe.  Further,  they  are 
more  readily  cured.  Tubercle  may  invade  the  urinary  organs  either 
from  the  kidneys  downward,  or  from  the  testes  upward;  these  are  the 
more  usual  modes  of  accession.  In  the  female,  a  labial  abscess  is 
often  the  initial  lesion,  as  an  inflammatory  deposit  in  the  testis  may 
be  in  the  male. 

It  will  not  be  necessary  for  clinical  purposes  to  occupy  much  time 
with  a  description  of  the  mode  in  which  tubercle  invades  the  normal 
tissues,  its  varieties,  or  its  chemistry ;  this  part  of  the  subject  will  be 
treated  of  at  length  in  one  of  the  later  volumes  of  this  series.  In  the 
form  of  gray  miliary  granulations,  or  as  yellow  caseous  masses  of 
various  sizes,  tubercle  may  be  met  with  indiscriminately  in  any  part 
of  the  genito-urinary  apparatus ;  it  is  found  in  the  kidney,  the  ureter, 
the  bladder,  the  prostate,  the  vesicula  seminalis,  the  testis,  the  epi- 
didymis, and  the  urethra ;  wherever  imjjlanted  there  is  no  knowing 


154  HAEEISON — DISEASES  OP  THE  KIDNEYS  AND  UEETEKS. 

where  it  will  spread  to.  It  will  be  seen  that  the  tendency  to  diffusion 
is  an  important  feature  in  relation  to  points  connected  with  diagnosis 
and  treatment. 

Urinary  tuberculosis,  when  the  deposit  is  in  relation  with  the  mu- 
cous tract  from  the  kidney  downward,  is  almost  sure  to  be  associated 
■vnth  one  or  other  of  three  symptoms,  though  as  a  rule  they  are  all  pres- 
ent in  varying  degree.  These  prominent  symptoms  are  hsematuria, 
frequent  micturition,  and  excess  of  or  change  in  the  urinary  mucus. 

Hsematuria  stands  in  relation  to  this  phase  of  the  disorder  as 
haemoptysis  does  to  pulmonary  phthisis ;  it  is  frequently  an  early 
symptom,  though  the  amount  of  blood  lost  in  this  way  is  generally 
small.  The  profuse  bleeding  of  urinary  tuberculosis  is  usually  asso- 
ciated Avith  its  later  stages  of  ulceration.  I  have  seen  a  considerable 
amount  of  blood  lost  from  those  excavating  ulcers  of  the  bladder 
which  are  common  in  the  course  of  this  disorder.  Then  there  is  fre- 
quency of  micturition,  which  as  a  rule,  when  the  kidneys  only  are  in- 
volved, is  not  exi^lainable  by  anything  that  the  surgeon  can  detect; 
and  lastly  there  is  a  considerable  excess  in  the  urinary  mucus.  These 
are  symptoms  which,  when  they  continue  and  are  otherwise  unac- 
counted for,  are  very  significant.  When  the  disease  has  made  more 
advance,  either  in  the  kidney,  bladder,  or  prostate,  the  urine  becomes 
charged  with  pus  and  other  signs  of  disintegrating  tissue.  It  is  curious 
to  notice  how,  even  under  these  circumstances,  the  urine  retains  an 
acid  reaction ;  it  is  not  until  it  undergoes  decomposition,  by  the  re- 
tention within  it  of  pus  and  unhealthy  lymph,  that  it  becomes  offen- 
sive and  ammoniacal.  A  person  who  is  infected  primarily  with  urin- 
ary tuberculosis  not  unfrequently  develops  symptoms  of  a  subacute 
form  of  peritonitis,  which  shows  that  the  disease  has  invaded  by 
contiguity  more  or  less  of  the  peritoneum.  In  this  way  I  have  on 
several  occasions  seen  the  disease  brought  to  a  termination  with  a 
swollen,  tender,  and  tympanitic  abdomen. 

Tubercle  of  the  kidney  in  its  earliest  form  is  not  unfrequently 
found  to  be  a  cause  of  incontinence  and  urinary  irritability  in  children. 
Many  children,  especially  males,  who  were  suspected  of  stone,  have 
proved  to  have  tubercular  kidneys.  In  an  instance  that  came  under 
observation,  the  prepuce  of  a  child  had  been  removed  with  the  hope 
that  this  might  relieve  the  urinary  irritability ;  excessive  renal  tuber- 
culosis, with  an  almost  entire  atrophy  of  one  kidney,  was  shown  after 
death  to  have  been  present.  The  following  case  illustrates  some 
features  to  which  reference  has  been  made : 

Case. — E.  S.,  aged  11,  a  schoolboy,  was  admitted  into  the  Liver- 
pool Koyal  Infirmary  on  June  19th,  1889.  About  eight  weeks  before 
admission  the  patient  after  micturition  passed  some  pus,  which  he 


EENAL  TUBERCULOSIS.  155 

described  as  being  in  little  nodules.  This  was  followed  by  tlie 
discliarge  of  small  clots  of  blood  at  intervals  after  micturition.  On 
admission,  in  addition  to  this  history,  he  micturated  frequently  with 
pain  referred  to  the  penis  and  neck  of  the  bladder.  He  was  a  fair, 
delicate-looking  boy,  and  for  twelve  months  had  often  complained  of 
headache.  The  urine  was  normal  in  appearance;  sp.  gr.  1.010,  acid; 
contained  mucus  and  a  trace  of  albumin.  On  June  10th  I  introduced 
a  sound  under  ether,  but  no  stone  could  be  detected.  Volkmann's 
bimanual  method  of  examining  the  bladder  was  then  employed,  when 
a  nodule  at  the  fundus  was  distinctly  felt.  In  the  evening  the  tem- 
perature rose  to  102°,  falling  in  the  morning  to  97°.  The  patient  was 
placed  on  a  milk  diet,  and  kept  in  bed.  24th :  It  was  noted  that  he 
was  slightly  delirious  during  the  night.  26th :  Had  a  restless  night. 
In  the  morning  he  passed  into  a  semi-conscious  state,  with  strabis- 
mus and  other  symptoms  of  acute  tubercular  meningitis.  Urine 
found  to  contain  tubercle  bacilli.  30th :  Died,  having  been  uncon- 
scious for  some  hours.  Necropsy. — Lungs  and  liver  contained  recent 
miliary  tubercles.  The  kidneys  were  tuberculous  and  both  ureters 
dilated.  The  mucous  membrane  of  the  bladder  was  covered  with 
a  number  of  superficial  ulcerations.  At  the  fundus  a  caseous  tuber- 
cular nodule  was  found  which  had  been  felt  during  life.  Convolu- 
tions of  brain  flattened,  lymph  at  base,  ventricles  very  much  dilated ; 
recent  miliary  tubercles  were  found  in  both  Sylvian  fissures. 

In  this  case,  the  detection  of  tubercle  bacilli  in  the  urine  assisted 
the  diagnosis.  In  distinguishing  doubtful  cases,  I  have  generally 
found  the  thermometer  of  great  assistance :  if  there  is  tubercle,  the 
temperature,  with  other  symptoms,  seldom  fails  to  give  us  a  good 
hint.  Eenal  tuberculosis  is  frequently  found  in  both  organs,  though 
it  may  be  only  suspected  or  advanced  in  one. 

Of  the  various  operations  employed  for  the  relief  of  urinary  affec- 
tions I  do  not  know  one  that  has  given  more  relief  than  cystotomy ; 
the  least  favorable  cases  in  my  experience  have  been  those  where  it  has 
been  resorted  to  for  conditions  arising  out  of  urinary  tuberculosis. 
When  undertaken  solely  with  the  object  of  relieving  the  intense  reflex 
irritation — the  frequent  micturition — which  often  attends  the  early 
deposit  of  tubercle  in  the  urinary  apparatus  from  the  kidney  down- 
ward, it  is  generally  a  failure.  When,  however,  it  is  performed  for 
the  purpose  of  giving  exit  to  the  products  of  tubercular  suppuration, 
to  pus,  lymph  flakes,  and  offensive  putrefying  urine,  then,  on  physi- 
cal grounds,  it  may  prove  of  some  service.  I  have  known,  in  cases  of 
urinary  tuberculosis,  the  desire  to  micturate  to  be  quite  as  distressing 
to  the  patient  though  urine  was  flowing  continuously  and  incontinently 
by  a  perineal  drain.  For  the  same  reason,  over-dilatation  of  the  fe- 
male urethra,  with  the  intention  of  causing  temporary  incontinence, 
does  not  relieve  the  reflected  irritability  of  urinary  phthisis.  The 
following  case  illustrates  some  of  the  points  referred  to : 


156  HAERISON — DISEASES   OF  THE  KIDNEYS  AND  URETEES. 

Case. — A  boy,  aged  4,  came  under  my  care  at  tlie  Liverpool 
Royal  Infirmary,  on  tlie  suspicion  that  lie  liad  a  stone  concealed 
somewhere  in  tlie  urinary  organs.  He  had  many  symptoms  of  this 
complaint,  but,  though  he  had  been  sounded  several  times,  no  calcu- 
lus could  be  felt.  He  was  a  child  of  strumous  parents,  and  was  sin- 
gularly bright  and  intelligent.  Twelve  months  previously  he  com- 
menced to  wet  his  bed  at  night,  and  to  suffer  from  urinary  irritability 
in  the  day-time.  Occasionally  small  quantities  of  blood  had  been 
detected  with  the  microscope  in  the  urine,  which  was  invariably  acid 
and  opaque.  Within  two  months  prior  to  his  admission  the  urine 
had  been  charged  with  mucus  and  pus,  the  expulsion  of  which  from 
his  bladder  caused  much  spasm  and  suffering.  To  aid  micturition 
and  to  mitigate  pain,  he  acquired  the  habit,  which  at  last  became  con- 
stant, of  pulling  at  his  penis.  He  seemed,  as  it  were,  to  milk  away 
the  urine  and  what  it  contained  from  his  bladder.  It  was  under 
these  circumstances  he  came  into  the  Infirmary,  when  it  was  found 
necessary  to  give  him  sedatives  freely.  The  urine,  always  granular- 
looking  and  opaque,  now  and  then  contained  something  which  looked 
more  like  the  white  of  an  egg  half  boiled  than  anything  else.  He  was 
sounded  under  ether,  but  nothing  abnormal  could  be  detected.  To- 
wards evening  he  generally  had  a  rise  of  temperature,  and  there  was 
a  hectic  tendency.  To  alleviate  the  constant  jiain  and  spasm  of  mic- 
turition, a  median  cystotomy  was  performed  for  drainage,  but  with 
little  benefit.  The  spasm  and  vesical  tenesmus  continued  unabated. 
In  the  course  of  a  month  the  child  died  with  renal  symptoms  and  a 
gradual  suppression  of  urine.  The  autopsy  showed  nothing  wrong 
with  the  bladder  or  urethra.  The  ureters  were  dilated,  and  the  kid- 
neys cystic  and  tubercular.  Some  of  the  cysts  communicating  with 
the  pelvis  of  the  kidney  contained  thick  gummy  looking  mucus,  simi- 
lar to  that  which  was  observed  in  a  more  diluted  form  in  the  urine ; 
the  cyst  walls  seemed  to  secrete  this  viscid  matter  which,  obviously, 
with  difficulty  had  found  its  way  along  with  the  urine  down  the  ure- 
ters. This  was  the  exjjlanation  of  the  dilated  ureters,  and  of  the  blad- 
der spasms  and  irritability  which  led  to  cystotomy  being  practised. 
Without  such  an  explanation  it  was  difficult  to  understand  how  the 
ureters  could  be  dilated  and  yet  no  stricture  exist  in  the  urethra. 

This  case  makes  prominent  the  following  points :  1.  That  urinary 
incontinence  or  irritability  in  children  may  proceed  from  renal  tuber- 
culosis. 2.  That  though  cystotomy  may  relieve  the  pain  and  spasm 
attendant  upon  the  expulsion  of  the  unhealthy  urine  from  the  blad- 
der, it  does  not  alleviate  the  symptoms  due  to  the  same  urine  passing 
down  the  ureters.  In  some  cases  of  this  kind  there  might  be  reasons 
for  performing  nephrectomy  or  even  opening  and  draining  a  cystic 
kidney,  so  as  to  prevent  the  constant  spasm  or  colic  which  is  aroused 
by  the  products  of  the  disorganized  organ  forcing  a  way  along  the 
ureters.  3.  It  illustrates  those  extremely  rare  instances  (of  which 
but  few  specimens  are  known  to  exist)  where  stones  in  the  bladder 
have  been  enclosed  in  fibrous  or  gelatinous  envelopes.     By  the  kind- 


KENAL  TtJBERCULOSIS.  157 

ness  of  Mr.  BickerstetL.  I  had  not  only  an  opportunity  of  examining 
and  preserving  a  well-marked  specimen  of  what  these  tubercular  cysts 
in  the  kidney  are  capable  of  pouring  along  the  ureters  into  the  blad- 
der, but  of  ascertaining  how  these  semi-fibrous  stones  are  probably 
formed.  This  subject  is  again  referred  to  in  connection  with  sound- 
ing the  bladder  for  stone.  The  possibility  that  in  a  tubercular 
subject  a  small  stone  in  the  bladder  may  be  wrapped  up  by  a  sort 
of  mucoid  investment,  furnished  by  a  cystic  kidney,  must  not  be 
lost  sight  of,  whether  or  not  the  explanation  thus  offered  as  to  the 
formation  of  these  calculi  is  a  satisfactory  one. 

In  the  diagnosis  of  urinary  tuberculosis  in  the  male,  the  careful 
examination  of  the  testes  and  jjrostate  with  the  finger  often  furnishes 
valuable  evidence  as  to  the  probability  of  tubercle  existing  in  the 
kidney  or  some  other  portion  of  the  genito-urinary  apparatus  which 
is  beyond  reach  of  manipulation.  When  deposit  in  these  parts  exists 
with  signs  of  functional  irritation  in  the  urinary  apxjaratus  generally, 
the  suspicion  that  tuberculosis  exists  is  exceedingly  strong,  particu- 
larly if  the  patients  are  adolescent  males  and  the  family  history  points 
to  a  strumous  diathesis.  The  following  case  which  I  saw,  in  consul- 
tation with  Dr.  Glynn,  in  the  Liverpool  Eoyal  Infirmary  illustrates 
the  importance  of  a  physical  examination  in  cases  of  this  kind : 

The  patient,  a  youth  aged  19,  was  admitted  in  Febrary,  1884. 
History. — ^A  strong  family  history  of  consumption.  Patient  had  good 
health  up  to  two  years  before  admission;  he  then  began  to  fail  gener- 
ally. For  twelve  months  he  had  been  suffering  from  a  short,  dry 
cough,  and  pain  in  the  region  of  the  kidneys  had  been  present  for 
three  months.  On  admission  he  was  much  emaciated.  There  was 
pain  on  pressure  in  the  left  lumbar  region  and  much  tenderness  over 
the  liver.  Urine  was  passed  twelve  to  fourteen  times  daily,  with 
smarting  pain  over  the  pubes  both  before  and  after  urination ;  it  con- 
tained much  pus,  but  no  bacteria  were  discovered.  The  prostate  was 
found  made  up  of  round  nodulated  masses.  In  the  right  testis  there 
was  some  deposit  in  the  globus  minor.  These  symptoms  continued 
until  death  took  place,  on  March  8th.  Autopsy. — Both  lungs  were 
studded  with  miliary  tubercles,  many  of  which  were  commencing  to 
soften.  In  the  transverse  and  descending  colon  there  were  two  large 
tubercular  ulcers,  about  twelve  inches  apart.  The  adrenals  were  full 
of  caseous  and  calcareous  matter.  The  kidneys  were  almost  destroyed, 
being  occujjied  by  caseous  nodules  and  cavities.  The  remaining  re- 
nal tissue  was  studded  with  tubercle  and  the  ureters  were  dilated. 
The  bladder  was  small  and  hypertrophied,  and  the  mucous  membrane 
covered  with  tubercular  ulcers.  The  prostate  was  softened  and  rid- 
dled with  cavities  containing  caseating  matter.  The  globus  minor  of 
the  right  testis  contained  a  tubercular  mass  the  size  of  a  large  pea. 

A  few  remarks  may  be  made  in  reference  to  the  treatment  of  a  tu- 
bercular condition  of  a  system  of  organs  which  is  more  common  than 


158  HAEEISON — DISEASES  OF  THE  KmNEYS  AND  UEETEES. 

we  may  at  first  siglit  be  inclined  to  believe.  In  tlie  early  stage  of  the 
disease  tlie  patient  requires  almost  the  same  attention  as  in  pulmo- 
nary phthisis,  so  far  as  climate,  diet,  clothing,  and  medicines  are  con- 
cerned. I  often  prescribe  small  doses  of  perchloride  of  mercury,  with 
advantage,  before  softening  takes  place.  A  suitable  sea-voyage  is 
sometimes  of  great  service  in  these  cases,  when  the  state  of  the  urine 
and  the  act  of  micturition  does  not  render  this  out  of  the  question. 
I  have  already  stated  that  cystotomy,  or  other  operative  proceeding, 
is  not  to  be  advised  unless  the  urine  becomes  so  greatly  disordered 
and  the  bladder  so  irritable  as  seriously  to  add  to  the  distress  of  the 
patient  in  voiding  it.  For  this  irritability  I  recommend  the  use  of 
morphine,  either  by  the  mouth  or  in  suppositories,  in  preference,  as 
a  rule,  to  anything  else.  The  quantity  of  morphine  required  in  some 
cases  of  urinary  tuberculosis  is  occasionally  considerable,  as  exem- 
plified in  the  following  instance : 

Case.— In  October,  1883,  I  saw,  with  Dr.  Paton,  of  Kock  Ferry, 
a  patient  (A.  W.,  aged  17)  who  was  subsequently  admitted  into  the 
Liverpool  Koyal  Infirmary  suffering  from  extensive  tuberculosis  of 
the  jjrostate  and  bladder.  In  January,  1884,  in  consequence  of  pain, 
hsematuria,  and  the  state  of  the  urine,  I  performed  median  cystot- 
omy. This  relieved  some  of  the  symptoms,  but  not  the  irritability. 
For  the  latter  morphine  was  prescribed,  the  daily  use  of  which  even- 
tually amounted  to  seventeen  grains.  Under  this  treatment,  with  cod- 
liver  oil  and  tonics,  he  steadily  improved.  In  1886,  he  reported  him- 
self as  perfectly  well,  but  he  had  not  been  able  entirely  to  discontinue 
the  morphine  habit. 

"When  the  urine  is  very  offensive,  the  bladder  may  be  washed  out 
with  some  antiseptic  fluid,  but  if  this  occasions  hemorrhage  from  the 
tubercular  spots,  it  had  better  be  dispensed  with.  Guyon  employs 
for  this  purpose  small  injections,  or  instillations  as  he  calls  them, 
of  nitrate  of  silver  in  preference  to  general  irrigation  of  the  viscus. 
As  a  local  application  to  the  tuberculous  bladder  I  have  found  more 
benefit  from  iodoform  suspended  in  mucilage  in  the  proportion  of  five 
grains  to  the  ounce. 

Much  stress  has  been  laid  on  the  infection  of  tubercle,  and  the 
necessity  of  early  removing  the  primary  deposits  when  they  can  be 
readily  got  at.  In  reference  to  this  point  Dr.  F.  W.  Rockwell,"  of 
Brooklyn,  remarks :  "  I  believe  the  treatment  of  tuberculous  testicle 
should  be  that  of  strumous  disease  of  any  other  gland,  and  that  early 
removal,  either  of  the  casous  masses  or  of  the  whole  diseased  organ, 
should  be  more  generally  practised  than  at  present." 

Tuberculin  has  been  employed  to  some  extent  in  the  treatment  of 
this  form  of  tuberculosis,  but  no  good,  so  far  as  I  can  ascertain,  came 
of  it.     Writing  upon  this  subject  Mr.  Hurry  Fenwick "  observes : 


DEFORMITIES  AND  MALPOSITIONS  OF  THE  KIDNEY.  159 

**  The  swelling  of  the  peri-tuberculous  tissues  led  to  suppression  and 
retention  of  urine,  and  the  use  of  the  lymph  was  liable  to  produce 
hemorrhages.  The  tuberculous  deposits  could  by  means  of  the 
cystoscope  be  seen  to  swell  up  in  the  same  way  as  in  the  skin,  and 
new  deposits  came  into  sight."  Where,  for  instance,  both  ureters  are 
involved,  it  is  obvious  from  such  observations  that  complete  stoppage 
of  urine  might  be  one  of  its  effects. 

There  is  a  remote  effect  of  tuberculosis  to  which  I  would  just 
refer.  We  occasionally  meet  with  cases  where  tubercles  have  become 
cured  by  cretification.  Such  deposits  in  the  bladder  and  prostate 
cause  frequent  micturition,  and  give  rise  to  a  suspicion  that  the  per- 
son is  suffering  from  stone.  The  history  of  the  case,  and  the  obser- 
vation that  these  calcareous  spots  are  fixed  and  not  movable  when 
felt  with  a  metal  sound,  usually  enables  the  practitioner  to  diagnose 
them  without  much  difficulty.  I  have  also  seen  similar  deposits  in 
the  kidneys  in  tubercular  subjects. 

From  the  foregoing  remarks  it  will  be  concluded  that  though 
nephrotomy  and  exploration  from  the  loin  may  sometimes  be  called 
for  to  relieve  pressing  symptoms  caused  by  a  tubercular  kidney,  the 
circumstances  which  would  indicate  a  nephrectomy  must  be  of  a  very 
exceptional  nature.  The  disorder  is  rarely  limited  to  the  kidney 
which  seems  to  demand  an  operation,  and  when  this  stage  has  been 
reached  the  prospects  of  curing  what  is  to  be  regarded  as  part  of  a 
urinary  tuberculosis  by  a  nephrectomy  must  be  considered  as  very 
remote.  A  tubercle  and  a  stone  represent  two  widely  different  con- 
ditions. 

Deformities  and  Malpositions  of  the  Kidney. 

The  kidneys  are  liable  to  various  kinds  of  congenital  alterations 
in  shape  and  position  with  which  the  practitioner  who  undertakes 
their  operative  treatment  should  be  acquainted. 

Probably  the  commonest  variation  in  shape  is  where  the  two  kid- 
neys are  connected  together  by  a  band  of  renal  tissue  passing  in  front 
of  the  spine  and  uniting  their  lower  ends.  This  is  usually  spoken  of 
as  the  horseshoe  kidney,  the  concavity  of  the  curve  looking  in  an 
upward  direction.  The  general  arrangement,  so  far  as  vessels  and 
ducts  are  concerned,  is  usually  in  accordance  with  what  would  apply 
where  the  two  kidneys  are  normally  developed.  Durham"  mentions 
an  instance  where,  in  a  good  example  of  this  unusual  disposition,  the 
ureters  passed  behind  the  united  organs.  In  some  instances  the  con- 
necting link  between  the  two  kidneys  is  at  their  upper  end,  when  the 
concavity  of  the  curve  looks  downward.  This  variety  is,  however, 
much  rarer  than  the  former.     Sir  William  Roberts'"  refers  to  a  speci- 


160  HAERISON — DISEASES  OF  THE   KIDNEYS  AND  UEETEES. 

men  wliere  tlie  ureters  were  seen  to  cross  eacli  other  on  their  way  to 
the  bladder. 

The  absence  of  one  kidney  has  been  frequently  observed  in  per- 
sons who  presented  no  symptoms  of  urinary  disorder  during  life. 
The  single  organ  is  invariably  hypertrophied  and  suffices  for  the 
entire  excretion  of  urine.  In  the  same  way  after  a  nephrectomy  a 
compensatory  process  takes  place  in  the  remaining  organ,  and  so  life 
is  sustained.  Of  29  cases  of  solitary  kidney  collected  by  Sir  Wil- 
liam Eoberts  from  various  sources,  22  occurred  in  males,  6  in  fe- 
males, and  in  one  case  the  sex  was  not  stated. 

Then  again  we  have  instances  of  misplaced  kidneys  such  as  those 
where  in  a  lobuled  form  the  entire  renal  tissue  is  limited  to  one  side, 
as  well  as  others,  where  though  one  organ  is  rightly  situated  the 
other  may  be  j)laced  over  the  sacro-iliac  synchondrosis  or  even  be- 
tween the  bifurcation  of  the  aorta.  Specimens  have  also  been  met 
with  where  the  kidneys  were  blended  together,  occupying  a  median 
position  in  front  of  the  great  vessels.  In  a  previous  section  a  ref- 
erence has  been  made  to  those  kidneys  which,  by  reason  of  anatomical 
peculiarities,  are  capable  of  altering  their  positions.  In  this  way 
painful  symptoms  due  to  movement  are  sometimes  produced,  and 
special  treatment  is  required  to  secure  their  more  complete  fixation. 

An  entire  absence  of  kidney  structure  has  not  infrequently  been 
found  in  the  foetus  and  the  new-born  child  of  full  maturity.  In  such 
instances  further  abnormalities  in  the  genital  organs  are  not  un- 
common. 

In  diagnosing  the  presence  of  both  kidneys  the  electric  cystoscope, 
as  I  have  already  stated,  has  proved  of  great  practical  value  and  has 
almost  led  to  other  methods  of  search,  such  as  catheterizing  the  ori- 
fices of  the  ureters,  being  abandoned. 

Dr.  Eeliquet,"  of  Paris,  has  published  a  case  illustrating  not  only 
a  remarkable  deformity,  but  a  variety  of  pathological  lesions  in- 
volving the  urinary  system.  The  specimen  is  one  of  hydronephrosis 
of  the  right  kidney  and  ureter,  with  calculous  pyelo-nephritis  of  the 
left  organ,  which  is  much  hypertrophied.  It  will  be  observed  from 
the  illustration  (Fig.  27)  that  two  large  tubes  proceed  from  the  de- 
generated right  kidney  to  the  bladder.  The  outer  and  larger  one  is 
the  dilated  ureter,  while  the  inner,  proceeding  from  the  apex  of  the 
kidney  downward,  is  a  patent  Miiller's  duct.  The  latter  structures, 
it  will  be  remembered,  are  the  origin  of  the  Fallofjian  tubes,  the  uterus, 
and  part  of  the  vagina,  and  are  generally  supposed  to  be  reduced 
to  the  veru  montanum  in  the  male,  where  any  trace  of  their  persis- 
tence is  rare.  In  Dr.  Reliquet's  case  the  remarkable  clinical  symp- 
toms were  no  doubt  due  to  the  compression  of  the  right  ureter  against 


DEFORMITIES  AJSTD  MALPOSITIONS  OF  THE  KIDNEY. 


161 


the  back  of  the  bladder  by  Miiller's  duct.  When  jjutrid  urine  had 
collected  in  the  dilated  right  kidney  and  ureter,  sufficient  to  overcome 
the  resistance  of  Miiller's  duct  (which  was  also  distended  with  fluid), 
it  escaped  into  the  bladder,  and  was  voided  during  micturition.     The 


Fig.  27.— Hydronephrosis  of  the  Eight  Kidney,  with  Calculous  Pyelo-Nephritis  and  Hypertrophy 
of  the  Left.  R.G,'Lett  kidney,  containing  calculi,  marlsed  1-7;  U.G^  left  ureter;  O.G,  orifice 
of  left  ureter  in  the  bladder;  R.D,  right  kidney;  U.D,  right  ureter;  O.D,  orifice  of  right 
ureter  in  the  bladder;  B./)^,  C/.Z)^,  upper  portion  of  Miiller's  canal;  U.D^,  V^,  lower  portion 
of  Miiller's  canal ;  V.R,  verumontanum ;  S.U.D^  bougie  in  right  ureter;  S.U.D^,  bougie  in 
lower  portion  of  Miiller's  canal. 

bladder  orifices  of  both  ureters  were  patulous,  and  reflux  of  urine  on 

the  left  side  was  no  doubt  the  cause  of  the  calculous  pyelitis.     The 

pressure  of  Miiller's  duct  prevented  this  back  flow  of  urine  along  the 

ureter  on  the  right  side,  hence  the  different  results  observed  in  the 
Vol.  I.— 11 


162  HAREISON — DISEASES  OF  THE  KIDNEYS  AND  UEETEBS. 

two  kidneys.  Tlie  specimen  was  taken  from  a  man  forty-five  years 
of  age.  Tliat  tke  persistence  of  Mliller's  ducts  may  prove  a  serious 
obstacle  to  tiie  passage  of  urine  into  the  bladder  there  can  be  no 
doubt,  from  the  evidence  afforded  in  this  as  well  as  in  other  cases ; 
while,  on  the  other  hand,  such  an  abnormality  may  exist  without 
producing  symptoms. 

Sufficient  illustrations  have  now  been  adduced  to  show  many  of 
the  difficulties  that  may  arise  both  in  diagnosing  and  treating  states 
of  renal  disease  under  such  circumstances.  In  the  case  of  a  patient 
urgently  requiring  surgical  relief  for  a  renal  affection,  the  possibility 
of  his  having  only  a  single  kidney  must  never  be  entirely  laid  aside. 
Persons  so  situated,  as,  for  example,  where  a  stone  is  impacted  in  the 
pelvis  or  ureter  of  the  solitary  organ,  would  doubtless  have  lost  their 
lives,  in  several  instances,  unless  such  a  contingency  had  been  rec- 
ognized and  promptly  acted  upon.  And  so  in  the  course  of  surgi- 
cal procedures,  as,  for  example,  nephrectomy,  we  must  not  forget 
either  that  the  organ  we  are  in  search  of  may  be  a  solitary  one,  or 
that  it  may  be  so  connected  with  its  fellow,  as  in  the  case  of  the 
horseshoe  kidney,  as  to  add  considerably  to  the  difficulty  as  well  as 
the  risk  of  dealing  -with.  it.  A  reasonable  knowledge  of  the  deformi- 
ties and  malpositions  of  the  kidney  will  in  some  instances  enable  the 
surgeon  to  recognize  them  beforehand ;  in  others  it  will  suggest  to 
him  the  best  course  to  take  when  in  actual  practice  he  meets  with 
them,  while  in  a  third  variety  it  will  enable  him  to  explain  symp- 
toms which,  in  naturally  disposed  parts,  would  be  simply  anomalous. 
It  is  with  these  objects  in  -sdew  that  a  brief  consideration  of  this 
aspect  of  the  subject  has  been  here  introduced.  However  interesting 
it  might  be,  I  have  j^urposely  avoided  discussing  it  from  the  develop- 
mental standpoint  as  being  hardly  within  the  scope  of  this  article. 

Hydatid  of  the  Kidney. 

Cysts  of  this  kind  connected  with  the  kidney  are  of  comparatively 
rare  occurrence,  and  are  more  frequently  met  with  in  other  parts  of 
the  body.  As  Thomas"  observes,  "  it  is  generally  found  to  exist  with 
greater  or  less  frequency  wherever  man  and  his  faithful  friend  and 
companion,  the  dog,  are  associated.  It  has  been  met  with  in 
Europe,  Asia,  Africa,  North  and  South  America,  and  in  all  the  col- 
onies of  Australasia;  while  chilly  Iceland  and  sunny  Australia  vie 
with  each  other  in  offering  this  unwelcome  immigrant  a  congenial 
home."  As  to  its  prevalence  in  America  Dr.  William  Osier, ^°  of  Bal- 
timore, observes :  "  In  this  section  of  the  country  it  is  rarely  met  with, 
and  in  the  inspection  of  over  800  bodies  only  three  instances  have 


HYDATID  OP  THE  KIDNEY.  163' 

been  found."  So  far  as  the  kidney  is  concerned,  in  a  recent  article 
by  Dr.  William  Gardner,"  of  Melbourne,  it  is  stated:  "In  Davaine's 
collection  of  566  cases  of  echinococcus  disease,  observed  in  man,  30, 
or  5.3  per  cent,  occurred  in  the  kidney.  The  left  kidney  is  found  to 
be  much  more  frequently  the  seat  of  the  disease  than  the  right,  and 
men  are  twice  as  often  attacked  as  women.  Out  of  68  cases  collected 
by  Beraud  48  opened  into  the  pelvis  of  the  kidney,  with  the  develop- 
ment in  some  cases  of  pyelitis." 

The  frequency  with  which  kidney  hydatids  communicate  with 
some  part  of  the  urinary  passages,  and  are  thus  voided,  is  a  matter  of 
general  observation.  In  this  way  a  spontaneous  cure  is  sometimes 
brought  about  and  the  precise  nature  of  the  disorder  may  pass  unno- 
ticed. This  may  to  some  extent  explain  the  supposed  rarity  of  renal 
infection.  In  a  case  I  have  elsewhere  referred  to,  which  came  under 
my  notice,  it  was  for  some  time  supposed  that  the  woman  was  suffer- 
ing from  renal  calculus  until  the  urine  was  examined  by  the  micro- 
scope and  the  parasite  detected. 

When  small,  hydatids  of  the  kidney  may  occasion  no  symptoms, 
these  being  for  the  most  part  due  either  to  the  rupture  of  the  cyst 
and  the  discharge  of  its  contents  into  the  pelvis  of  the  viscus,  or  to 
the  pressure  exercised  on  the  organ  by  the  increasing  dimensions  of 
the  growth.  This  increase  has  sometimes  become  so  considerable  as 
to  interfere  with  the  function  of  the  part,  thus  leading  to  a  compensa- 
tory hypertrophy  in  the  opposite  organ.  Again  it  has  been  noticed 
that  an  hydatid  of  the  kidney  has  led  to  a  mobility  of  the  organ  for 
which  an  operation  has  become  necessary,  and  thus  the  parasite  has 
been  accidentally  discovered.  An  hydatid  involving  the  kidney  can 
sometimes  be  distinguished,  on  manipulation,  by  a  characteristic 
fremitus  or  kind  of  friction-feel.  This  is  not  always  recognizable,  and 
its  absence  has  therefore  but  little  significance. 

The  most  trustworthy  method  of  diagnosis  is  that  obtained  by  the 
exploring  trocar,  which  permits  of  the  withdrawal  of  some  of  the  fluid 
contents  and  the  recognition  of  the  characteristic  booklets  by  the 
microscope.  By  the  detection  of  these  distinguishing  products  in 
the  fseces  I  was  able,  in  a  case  referred  to  under  the  section  on  hydro- 
nephrosis, to  diagnose  a  pelvic  hydatid  of  considerable  standing.  It 
must,  however,  be  remembered  that  the  introduction  of  a  very  fine 
trocar  and  cannula  into  an  hydatid  cannot  invariably  be  done  with 
impunity,  and  when  this  method  of  diagnosis  has  necessarily  to  be 
adopted  the  surgeon  should  be  prepared  with  all  the  appliances  for 
at  once  proceeding  with  whatever  radical  measure  may  be  selected. 
Gardner'"  observes:  "Simple  jjuncture,  although  generally  devoid 
of  risk,  has  been  known  to  cause  sudden  death,  sometimes  apparently 


164  HAEEISON — DISEASES  OP  THE  KIDNEYS  AND  URETERS. 

from  sliock.  The  objection  to  puncture  as  the  mode  of  treatment  for 
internal  hydatids,  however,  lies  less  in  the  occasional  perils  of  the 
operation  than  in  its  frequent  inefficacy."  It  has  been  stated  that 
these  symptoms  are  due  to  the  poisonous  nature  of  the  contents  of 
these  cysts  and  their  absorption,  but  I  do  not  think  there  is  sufficient 
proof  of  this. 

Hydatid  cysts  sometimes  assume  a  considerable  size.  In  one  case 
operated  upon  by  Spiegelberg,  '^  a  woman,  aged  forty-two,  had  a  retro- 
peritoneal echinococcus  cyst  connected  with  the  omentum,  the  large 
and  small  intestines,  and  the  right  kidney,  which  was  mistaken  for  an 
ovarian  cyst ;  the  fibrous  capsule  and  a  portion  of  the  right  kidney 
were  removed.  The  patient  died  twenty -six  hours  after  the  opera- 
tion. 

As  a  rule  the  cyst  is  situated  in  the  substance  of  the  kidney, 
though  at  times  it  is  found  insinuating  itself  between  the  capsule  and 
the  gland.  The  tumors  are  liable  to  certain  accidents,  such  as  rupture 
from  the  effects  of  muscular  as  well  as  outside  pressure,  and  in  this 
way  a  spontaneous  cure  may  eventually  be  brought  about.  They  often 
form  adhesions  to  surrounding  parts  and  so  implicate  organs  other  than 
those  in  which  they  may  originate.  Inflammation  occasionally  occurs 
within  them,  and  suppuration  may  proceed  to  their  spontaneous  burst- 
ing and  the  escape  of  their  contents,  either  into  a  natural  outlet  as 
the  urinary  passage,  or  even  into  the  intestines.  They  may  degen- 
erate, as  Sir  William  Roberts  has  demonstrated,  and  be  converted 
into  cretaceous  masses  consisting  of  x)hosphate  of  lime,  cholesterin 
plates,  and  fatty  granules. 

Surgically  speaking,  the  treatment  of  these  cysts  relatively  to  the 
kidney  consists,  after  medical  measures  have  failed  either  to  elimi- 
nate or  to  poison  the  parasite,  in  first  exploring  them  with  an  aspira- 
tor needle  and  then  proceeding  to  open  them  freely  for  the  purpose 
of  clearing  out  their  contents  and  draining  them.  In  the  case  of  a 
renal  hydatid  this  should  be  effected  through  the  loin  by  such  an  in- 
cision as  is  described  in  connection  with  nephrotomy,  by  means  of 
which  the  cyst  can  be  effectuall}^  opened,  scraped,  and  drained.  In~ 
certain  instances  and  to  facilitate  the  last-named  object  the  side  of 
the  opening  in  the  cyst  may  be  secured  by  suture  to  the  correspond- 
ing lips  of  the  cutaneous  incision.  In  the  case  of  the  kidney,  as  Dr. 
Gardner  observes,  there  are  instances  in  which  it  is  necessary  to  select 
nephrectomy ;  this  conclusion,  however,  is  not  likely  to  be  arrived  at 
until  the  sac  has  been  fully  explored.  Dr.  Bond's  mode  of  dealing 
with  renal  hydatids'^  is  referred  to  by  Dr.  Gardner  in  his  paper  as 
being  the  ideal  method,  and  is  also  commended  because  time  is  saved 
in  the  after-treatment ;  he  thus  illustrates  it : 


TUMORS   OF  THE   KIDNEY. 


ler 


Case. — A  married  woman,  aged  35,  suffering  from  hydatid  of  the 
left  kidney.  The  usual  lumbar  incision  was  made  and  the  cyst 
exposed  and  freely  opened,  after  being  punctured  with  a  hollow 
needle.  The  sides  of  the  cyst  were  grasped  with  forceps,  and  by 
douching,  a  large  mother-cyst  was  withdrawn.  The  envelope  was 
dried  and  closed  with  a  continuous  suture,  and  then  the  external  inci- 
sion was  adjusted  in  the  usual  manner.  The  wound  was  dressed  for 
the  first  time  on  the  eighth  day  and  found  to  be  firmly  united.  She 
left  the  hospital  on  the  fourteenth  day. 


Tumors  of  the  Kidney. 

The  subjoined  list  of  tumors,  given  in  tabular  form,  shows  at  a 
glance  the  various  kinds  of  enlargement  of  the  organ,  or  of  the  struc- 
tures immediately  connected  with  it,  which  clinically  constitute  a  renal 
tumor.  To  render  the  table  complete  we  include,  on  the  one  hand, 
some  inflammatory  and  other  swellings,  which  though  not  neo- 
plasms, are  at  the  bedside  regarded  as  tumors ;  and,  on  the  other, 
some  rare  or  minute  growths  which  are  definite  pathological  new 
formations,  though  of  insignificant  clinical  importance. 


I.  Of  congenital 

oriffin. 


Sarcoma. 
Cystic  disease. 
Hydronephrosis, 
i^  Cavernous  tumors. 


II.   Of  post-con- 
genital origin. 


Extra-renal. 


f  Abscess. 
J  Cysts. 

I  Myxo-lipoma. 

(^  Tumors  of  the  adrenal. 

(  Hydro-  and  pyo-nephrosis. 

Pelvic <  Villous  tumor. 

(  Carcinoma. 


Hydatid  cysts. 

Cystic  disease. 

Tubercular  disease. 

Lymphadenoma. 

Syphilitic  deposits. 

Lipoma. 

Fibroma. 

Sarcoma. 
I   Adenoma. 
[   Car<;inoma. 
I  Secondary  growths. 


^  Glandular  and  capsular. 


The  tumors  are  arranged  primarily  in  two  groups.  The  first  in- 
cludes those  of  congenital,  and  the  second  those  of  post-congenital, 
origin.  This  arrangement  is  warranted  by  both  clinical  and  patho- 
logical experience.  Clinically  we  recognize  the  rarity  of  renal  tumors 
during  late  childhood  and  early  adult  life,  while  they  are  compara- 
tively not  uncommon  before  five  or  after  thirty.     Pathologically  it  is 


166  HAERISON — DISEASES  OF  THE  KEDNEYS  AND  URETERS. 

found  that  the  early  growths  have  a  minute  structure  unlike  the  later 
growths,  and  one  which  indicates  that  they,  like  the  congenital  cystic 
disease  and  hydronephrosis,  are  referable  to  abnormalities  of  devel- 
opment. It  is  in  the  congenital  sarcomata  only  (though  these  rarely 
show  themselves  late  in  life)  that  a  complex  minute  structure  is  met 
with,  including  such  various  tissues  as  striped  muscle,  fat,  and  other 
connective  and  glandular  tissues,  and  pointing  to  their  origin  from 
structures  derived  from'  the  Wolffian  body  or  intermediate  cell-mass, 
and  included  in  the  substance  of  the  true  kidney.  To  congenital 
cystic  disease  a  similar  origin  has  been  ascribed ;  the  cysts  are  said 
to  be  derived  from  the  remains  of  the  Wolffian  body  (Shattuck). 
Hydronephrosis  the  result  of  congenital  abnormalities  is  much  more 
frequent  than  the  cystic  disease,  and  has  a  considerably  greater  clini- 
cal importance.  Dermoid  cysts  are  mentioned,  but  it  is  doubtful  if 
any  examples  have  actually  been  met  with  in  the  human  subject. 
Cavernous  tumors  are  small,  and  give  rise  to  no  symptoms.  They 
probably  correspond  in  origin  and  growth  to  similar  tumors  in  the 
skin. 

The  post-congenital  tumors  are  subdivided  into  three  groups  ac- 
cording to  their  anatomical  position.  Of  those  which  are  extra-renal, 
abscess  has  already  been  dealt  wdth.  Extra-renal  serous  cysts  are 
rare,  and  their  etiology  is  not  very  well  understood.  Large  myxo- 
lipomatous  tumors  occasionally  grow  from  the  peri-renal  fat,  and 
are  properly  included  among  the  renal  tumors,  as  this  fat  has  a  de- 
finite anatomical  relation  to  the  kidney.  Tumors  of  the  adrenal  are 
often  so  intimately  connected  with  the  kidney  that  it  is  impossible 
to  differentiate  them  clinically,  as  may  generally  be  done  when  the 
enlargement  is  in  the  spleen,  liver,  glands,  or  bowel.  And  when  the 
tumor  is  malignant  it  infiltrates  the  kidney  at  such  an  early  stage 
that  it  may  be  impossible,  even  post  mortem,  to  decide  in  which 
organ  it  originated. 

The  pelvic  group  include  hydro-  and  pyo-nephrosis,  already  treated 
of,  villous  tumor  or  papilloma,  and  carcinoma.  The  pelvic  mucous 
membrane  has  the  same  structure  as  the  lining  membrane  of  the 
bladder,  and  it  is,  therefore,  as  we  should  expect,  subject  to  the  same 
varieties  of  new  growth.  Villous  tumor  is  uncommon,  but  may  attain 
a  considerable  size.  It  is  exactly  like  that  which  grows  in  the  blad- 
der. Squamous-celled  epithelioma  is  the  usual  kind  of  carcinoma 
met  with  in  this  locality ;  it  is  more  frequent  than  the  preceding. 
Colloid  carcinoma  is  the  only  other  variety.     It  is  very  rare. 

The  glandular  and  capsular  group  is  composed  of  many  species, 
of  which  tubercular  disease,  sarcoma,  and  carcinoma  are  by  far  the 
most  important.     Hydatid  cysts  may  occupy  any  position  in  regard 


TUMORS  OF  THE   KIDNEY.  167 

to  the  organ.  They  are  much  less  frequent  here  than  in  the  liver, 
but  can  hardly  be  regarded  as  curiosities.  Cystic  disease  is  rare.  It 
may  give  rise  to  great  enlargement  of  one  or  both  organs  with  symp- 
toms of  Bright' s  disease.  The  tubercular  affections  have  been  de- 
scribed. Lymphadenomatous  growth  in  the  kidney  sometimes  forms 
a  part  of  Hodgkin's  disease.  Syphilitic  gummata  are  distinctly  rare 
in  the  kidney.  When  seen  they  are  found  accidentally  post  mor- 
tem. Unlike  similar  deposits  in  the  liver  they  do  not  appear  to 
attain  clinically  recognizable  proportions.  Lipoma  in  the  kidney 
substance  is  rare  and  small.  The  fibromata  described  are  very  small, 
but  are  frequently  observed.  Neither  of  the  two  latter  have  any 
clinical  significance.  Of  the  sarcomata  the  small  round-celled  variety 
is  that  which  is  almost  constantly  met  with ;  but  some  very  interest- 
ing specimens  of  a  vascular  or  hemorrhagic  tumor  of  the  kidney  have 
been  recorded,  and  it  is  not  decided  whether  they  should  be  called 
angeio-sarcoma  or  hemorrhagic  carcinoma.  Adenoma  occurs  as 
small,  more  or  less  encapsuled  tumors,  having  a  tubular  or  cystic 
structure.  The  typical  carcinoma  is  also  tubular  and  sometimes 
cystic ;  but  there  is  at  present  no  satisfactory  account  of  the  patho- 
logical varieties  which  may  occur  in  this  region.  Secondary  sarcoma 
and  carcinoma  are  less  frequent  in  the  kidney  than  in  the  lungs  or 
liver,  and  the  growths  rarely  attain  sufficient  size  to  seriously  impede 
the  functions  of  the  organ,  except  in  the  case  of  the  direct  infiltration 
of  a  neighboring  tumor. 

I  am  indebted  to  Mr.  F.  T.  Paul,  of  Liverpool,  for  revising  for  the 
purposes  of  this  work,  so  far  as  renal  tumors  are  concerned,  the  classi- 
fication which  was  originally  drawn  up  by  him  as  an  introduction  to  a 
discussion  on  the  new  growths  of  the  bladder,  prostate,  and  kidney.^* 
The  investigation  on  which  this  is  based  was  undertaken  at  the  re- 
quest of  the  British  Medical  Association  by  a  committee  consisting 
of  Mr.  Paul,  Mr.  Rushton  Parker,  Dr.  Alexander,  and  myself. 

From  the  foregoing  classification  it  will  be  seen  that  tumors  of 
the  kidney  may  for  clinical  purposes  be  considered  as  of  two  kinds, 
namely,  innocent  and  malignant.  The  broad  distinctions  between 
these  two  classes  are  those  which  are  recognized  as  being  applicable  to 
growths  generally  wherever  they  may  occur  in  the  human  body.  It 
will  be  well,  in  the  first  place,  to  ascertain  the  circumstances  which 
would  lead  us  to  believe  that  a  kidney  is  the  subject  of  a  growth  or 
enlargement  bringing  it  under  either  of  these  two  denominations,  and 
the  features  which,  when  present,  enable  us  to  differentiate  between 
varieties  of  these  formations. 

It  is  generally  admitted  that  among  abdominal  enlargements  and 
tumors  those  taking  their  origin  in  the  kidney  are  probably  the  most 


168  HARRISON — DISEASES   OF  THE  KIDNEYS  AND  URETERS. 

difficult  to  diagnose.  They  are  not  unfrequently  associated  with 
ascites,  and  when  this  complication  exists  the  task  of  drawing  distinc- 
tions, especially  in  stout  persons,  is  by  no  means  an  easy  one.  The 
encroachments  proceeding  from  other  organs  such  as  the  liver,  spleen, 
suprarenal  capsules  and  the  growths  connected  with  them,  for  in- 
stance hydatids,  present  other  sources  of  embarrassment.  Further, 
we  have  to  take  into  consideration  the  possibility  of  a  renal  growth 
being  initiated  by  one  of  those  tumors  taking  their  origin  in  the  cap- 
sule of  the  kidney  or  in  the  connective  tissue  surrounding  it,  which 
have  more  recently  been  described  by  Dr.  Vander  Veer  ^^  under  the 
title  of  "  Retro-Peritoneal  Tumors."  Then  there  are  abnormalities  in 
the  position  and  relations  of  the  abdominal  viscera  of  not  unfrequerit 
occurrence  which  have  added  in  no  small  measure  to  the  difficulties 
connected  with  making  a  diagnosis.  In  these  ways  sources  of  doubt 
in  some  cases  may  easily  arise,  rendering  it  almost  impossible  to 
arrive  at  a  conclusion  without  the  assistance  of  some  kind  of  explor- 
atory operation.  In  coming  to  a  diagnosis,  or  at  all  events  in  en- 
deavoring to  do  so,  it  is  best  in  most  cases  to  proceed  step  by  step 
by  what  is  well  recognized  in  surgery  as  the  process  of  exclusion.  In 
these  investigations  we  shall  do  well,  where  it  is  necessary,  to  avail 
ourselves  of  the  assistance  that  is  often  rendered  by  the  aspirator  and 
exploring  needle,  by  a  careful  quantitative,  qualitative,  and  micro- 
scopical examination  of  the  urine,  in  addition  to  the  ordinary  modes 
of  manipulative  examination.  In  some  cases  the  cystoscope,  in  de- 
termining the  action  of  the  respective  ureters  as  well  as  the  nature  of 
the  fluids  they  emit,  will  prove  of  service.  Again,  instances  will  occur 
where  in  defining  the  nature  and  limits  of  a  tumor  in  the  kidney  such 
a  complete  relaxation  of  the  abdominal  parietes  will  be  required 
as  can  only  be  secured  by  the  administration  of  an  ansesthetic.  In 
the  female  an  examination  of  the  pelvic  contents  by  the  vagina  may 
be  called  for,  for  instance  in  the  differential  diagnosis  between  an 
ovarian  tumor  and  an  enormous  fluid  dilatation  of  the  kidney,  as  re- 
ferred to  in  connection  with  the  subject  of  hydronephrosis.  In  a 
male  child,  in  a  doubtful  kidney  case,  I  remember  an  instance  where 
the  detection,  by  the  finger  in  the  rectum,  of  a  stone  impacted  in 
the  lower  end  of  the  ureter  proved  of  material  importance.  Then, 
again,  the  faeces  should  not  be  allowed  to  go  without  inspection;  the 
absence  or  presence  of  bile  in  them  may  throw  some  light  on  an  ob- 
scure case.  Writing  in  reference  to  the  diagnosis  of  retro-peritoneal 
tumors  Dr.  Vander  Veer  remarks  as  being  of  service  "  the  rectal  in- 
sufflation of  hydrogen  gas,  with  the  distention  of  the  stomach ;  more 
especially  where  a  careful  examination  has  been  made  before  and  the 
percussion  areas  have  been  outlined  upon  the  abdomen.     The  pro- 


TUMORS  OF  THE  KIDNEY.  169 

cess  of  insufflation  should  be  watched,  that  the  relation  of  the  intes- 
tinal tube  to  the  tumor  maybe  established."  This  method  of  in- 
sufflation has,  I  know,  been  advantageously  used  in  determining  the 
nature  of  doubtful  abdominal  growths.  By  these  means  and  in  these 
directions  search  may  often  be  advantageously  made. 

The  points  ujjon  which  stress  has  been  laid,  as  distinguishing  kid- 
ney tumors  of  sufficient  dimensions  to  be  appreciable  by  manual 
examination,  are  these :  That  the  large  intestine  is  in  front  of  the 
growth.  This  is  not  generally  applicable,  for,  as  Mr.  Bruce  Clarke"" 
remarks,  the  colon  is  often  displaced  congenitally.  This  coincidence 
was  found  in  a  case  which  occurred  under  Dr.  Black's  care  in  St. 
Bartholomew's  Hospital.  As  renal  tumors  grow  in  directions  where 
the  resistance  is  least,  there  is  seldom  anything  like  a  lumbar  pro- 
jection; as  Sir  William  Jenner  remarked,"  "Tumors  due  to  disease 
of  the  kidney  enlarge  in  front;  while  abscesses  and  other  lesions 
which  may  simulate  renal  tumors  often  cause  considerable  posterior 
projection."  The  kidney  is  rounded  naturally  and  remains  so  as  it 
grows ;  as  Jenner  observes,  "  it  has  no  sharp  edges  and  in  disease  never 
loses  this  peculiarity."  Kidney  growths  are  rarely  influenced  ma- 
terially by  inspiration.  This,  however,  is  not  of  universal  applica- 
tion, for  as  Morris  says,  "  I  have  seen  a  renal  tumor  descend  as  much 
as  an  inch  by  a  deep  inspiration  and  fall  forward  or  backward  by 
its  own  weight  with  the  movements  of  the  body."  The  shape  of  a 
tumor,  if,  for  instance,  it  is  a  very  pendulous  one,  may  in  some  meas- 
ure determine  this,  as  I  have  had  occasion  to  notice.  The  position  of 
the  most  prominent  portion  of  the  tumor  relative  to  the  adjacent  parts 
is  also  of  importance  to  notice.  This  usually  corresponds  some- 
where about  with  the  line  of  the  umbilicus.  It  should  also  not  be 
lost  sight  of  that  on  the  right  side  alterations  in  the  shape  and  posi- 
tion of  the  liver  have  been  mistaken  for  kidney  tumors,  while  on  the 
left  the  spleen  and  the  corresponding  kidney,  in  a  similar  way,  have 
been  confounded.  A  surface  inequality,  as,  for  instance,  an  interposed 
line  of  resonance  on  percussion,  will  often  serve  to  indicate  on  careful 
examination  these  regional  distinctions.  Some  of  these  diagnostic 
points  are  well  shown  in  the  accompanying  figure  from  a  paper  on 
congenital  sarcoma  of  the  kidney  by  Mr.  Paul.^' 

Though  in  the  majority  of  cases  we  shall  be  safe  in  concluding 
that  a  kidney  is  the  subject  of  a  tumor,  it  may  hardly  be  possible  to 
differentiate  between  the  varieties  of  new  growth  in  contradistinc- 
tion to  those  dilatations  and  distentions  of  the  organ  which  have  oc- 
cui)ied  the  earlier  x>ortions  of  this  article.  I  may,  however,  mention 
some  general  conclusions  derived  from  experience  which  may  be 
of  assistance  in  enabling  us  to  make  this  distinction.     The  smaller 


170 


HAEEISON — DISEASES  OF  THE  KIDNEYS  AND  URETEES. 


kinds  of  irmoceiit  growths,  whicli  do  not  attain  any  considerable  size, 
including  cysts,  are  rarely  discovered  till  after  death;  nor  do  they 
appear  to  cause  symptoms  or  to  be  otherwise  tjian  incidental  to  other 
diseases.  In  the  case  of  kidney  symptoms  occurring  in  syphilitic  or 
scrofulous  subjects,  the  possibility  of  a  gumma  or  a  tubercle  will  not 
be  forgotten. 

Turning  to  the  malignant  type  of  tumors,  their  often  considerable 
size  and  rapid  growth  will  not  fail  to  arrest  our  attention.  These  in 
their  development  are  either  jDrimary  or  secondary.  The  discovery 
of  a  primary  mahgnant  growth  in  any  of  the  adjacent  parts  such  as 
the  rectum,  prostate,  bladder,  intestines,  or  the  breast,  where  the 
diagnosis  is  more  readily  made,  will  afford  an  explanation  for  the 
sequence  of  symptoms  which  now  point  to  the  kidney.     Medullary 

cancer  (sarcoma)  in  chil- 
dren, when  it  affects  the 
kidney,  sometimes  as- 
sumes enormous  dimen- 
sions {vide  Fig.  28).  When 
cancer  involves  the  kid- 
ney in  a  primary  form  it 
is  usually  limited  to  one, 
in  secondary  cancer  both 
organs  are  generally  im- 
plicated. As  stone  in  the 
bladder,  as  an  irritant  in 
a  cachectic  subject,  is  be- 
lieved sometimes  to  be 
the  exciting  agent  of  a 
cancer,  so  may  it  be  in 
the  case  of  the  kidney. 
A  villous  growth  in  the 
bladder,  as  I  have  seen  in  more  than  one  instance,  is  occasionally 
attended  with  a  similar  one  in  the  kidney. 

The  symptoms  of  a  renal  neoplasm  are  by  no  means  well  defined 
or  constant.  An  increased  bulk  in  the  organ  is  probably  the  leading 
feature  in  conjunction  with  what  I  would  speak  of  as  the  natural 
history  of  its  development  and  the  circumstances  attending  it.  Irri- 
tation of  the  bladder,  hsematuria,  personal  appearance,  pain  in  the 
part,  oedema  of  one  or  both  legs,  engorgement  of  the  abdominal 
cutaneous  veins,  all  have  their  significance;  these  indications  of  a 
structural  lesion  must  be  weighed  in  conjunction  with  the  application 
of  those  diagnostic  tests  to  which  reference  has  already  been  made. 
Lastly  comes  the  question  as  to  how  these  neoplasms  are  to  be 


Fig.  28.— a  Congenital  Renal  Tumor  of  the  Left  Side 
Weighing  Six  Pounds  in  a  Child  Aged  One  Year.  It 
shows  the  characteristic  displacement  of  the  colon,  and 
the  general  interference  which  must  have  been  caused 
to  other  organs  by  its  immense  size.  (From  a  post- 
mortem photograph.) 


DISEASES   OF  THE   UEETERS.  171 

treated — to  what  extent  is  it  legitimate  to  remove  them,  by  the  extir- 
pation of  the  kidney  through  either  a  lumbar  or  abdominal  incision? 
This  can  only  be  answered  by  carefully  weighing  in  a  given  case  the 
questions :  Can  the  disease  be  entirely  removed  at  no  very  great  and 
immediate  risk  to  life,  so  as  to  give  the  patient  a  fair  chance  of  future 
immunity?  or.  Are  the  symptoms  of  such  intensity,  so  far,  for  instance, 
as  pain,  bleeding,  or  urinary  retention  are  concerned,  as  to  justify  the 
surgeon,  in  the  absence  of  all  other  modes  of  relief,  in  making  any  at- 
tempts of  an  operative  nature  that  may  seem  to  be  within  reach?  To 
both  of  these  questions  there  are  cases  of  an  exceptional  nature  where 
the  answer  must  be,  in  the  interest  of  suffering  humanity,  in  the 
affirmative.  The  outlook  in  the  growths  of  early  life,  there  can  be 
no  doubt,  is  most  unfavorable.  As  Mr.  Paul  observes,  "that  all 
these  congenital  tumors  are  malignant  is  clearly  established  by  a 
most  valuable  paper  drawn  up  by  Mr.  Sutton, '"  in  which  he  shows 
that  out  of  thirty -five  operations  for  the  removal  of  renal  sarcoma  in 
children  under  six  years  of  age  fifteen  recovered,  but  all  died  within  a 
year  from  recurrence  of  the  growth.  Thus,  however  interesting  it  is  to 
us  as  pathologists  to  study  cases  such  as  these,  it  is  a  somewhat  dis- 
heartening reflection  that  up  to  the  present  they  remain  hopeless 
from  the  clinical  point  of  view."  A  reference  to  the  methods  of  per- 
forming nephrectomy  and  operations  for  the  exploration  of  the  kidney 
will  be  found  in  a  preceding  section. 

It  has  been  stated  that  some  of  these  neoplasms  may  be  checked 
in  their  course  toward  destruction  by  various  agencies;  of  these, 
iodide  of  potassium  and  Chian  turpentine  appear  to  have  given  some 
slight  evidence  of  their  efficacy  in  this  direction. 

It  is  too  soon  as  yet  to  say  anything  definite  in  regard  to  the 
use  of  the  erysipelas  toxines  in  the  treatment  of  malignant  neo- 
plasms of  the  kidneys  or  other  organs.  Their  therapeutic  value, 
if  they  possess  any,  can  be  demonstrated  only  by  actual  experience 
in  a  long  series  of  cases. 

DISEASES   OF   THE  URETERS. 

The  tubular  connections  between  the  kidneys  and  the  bladder,  by 
means  of  which  the  urine  is  carried  from  the  glands  where  it  is  se- 
creted to  the  reservoir  in  which  it  is  temporarily  contained,  have 
recently  received  a  considerable  amount  of  attention  from  a  patho- 
logical as  well  as  a  surgical  point  of  view.  In  fact  the  surgery  of  the 
ureters  is  now  as  progressive  as  that  which  applies  to  the  parts  these 
tubes  connect.  What  has  been  already  accomplished  stands  out  in 
remarkable  contrast  with  the  state  of  things  which  existed  prior  to 


172  HAEEISON — DISEASES  OF  THE  KIDNEYS  AND  URETEES. 

the  present  decade  and  cannot  fail  to  serve  as  an  incentive  to  further 
advances.  When  we  consider  that  an  injury  to  a  ureter  is  almost 
certain  to  result  in  the  ultimate  loss  of  the  corresponding  kidney, 
while  its  obstruction  by  a  calculus  may  be  attended  by  still  more  dis- 
astrous consequences,  it  is  almost  impossible  to  overestimate  the 
importance  of  the  subject.  This  importance  is  considerably  en- 
hanced by  the  knowledge  that  in  the  whole  of  their  course  these 
tubes  are  within  reach  of  the  surgeon  without  any  very  great  dif- 
ficulty so  far  as  the  operative  procedures  are  concerned. 

Injuries   of  the   Ureters. 

Protected  as  they  are  by  the  parts  surrounding  them,  it  might  ap- 
pear that  lesions  of  these  tubes  are  well-nigh  impossible.  This, 
however,  is  not  the  case,  for  we  shall  find  examples  constantly  occur- 
ring of  their  rupture,  laceration,  and  division. 

Kupture  of  a  ureter  is  usually  caused  by  the  application  of  very 
great  violence  to  the  trunk  or  abdominal  region  as  by  crushes  and 
squeezes.  It  may  also  be  occasioned  by  gunshot  injuries  or  by  the 
bursting  of  explosive  shells,  where  the  lesions  are  usually  extensive 
and  complicated.  A  ureter  has  been  severed  by  a  stab  wound,  and 
accidentally  divided  by  the  knife  of  the  surgeon  in  the  course  of  an 
operation.  Its  lining  membrane  may  be  lacerated  sufficiently  by  the 
descent  of  a  rough  calculus  to  cause  a  cicatrix  and  a  subsequent 
stricture  or  narrowing  of  the  tube.  Kupture  from  external  violence 
most  frequently  occurs  in  immediate  proximity  to  the  pelvis  of  the 
kidney.  In  one  instance  I  saw,  where  it  was  comj)licated  with  fracture 
of  the  lower  ribs,  I  have  no  doubt  it  was  caused  by  the  man,  while 
in  a  state  of  intoxication,  being  squeezed  between  a  heavy  wagon  and 
a  large  stone.  The  patient  died  the  day  following  his  admission  to 
the  Liverpool  Northern  Hospital.  Some  blood-stained  urine  was 
removed  by  the  catheter,  but  beyond  this,  and  the  general  nature  of 
the  injury,  there  was  nothing  to  indicate  that  the  left  ureter  had  been 
torn  across  immediately  below  the  kidney,  as  shown  by  the  autopsy. 
The  late  Mr.  Stanley"  recorded  two  instances  of  this  injury :  one 
where  the  diagnosis  was  verified  by  an  examination  after  death, 
which  took  place  ten  weeks  after  the  injury,  and  the  other  where, 
though  the  symptoms  pointed  to  the  probability  of  this  lesion  being 
present,  the  patient  recovered.  In  both  of  these  cases  a  prominent 
feature  was  the  collection  in  the  cellular  tissue  behind  the  peritoneum 
of  fluid  resembling  urine,  which  had  to  be  removed  by  tapping.  Mr. 
Poland  "  has  also  recorded  another  instance  where,  consequent  on  a 
crush  between  a  railway  i^latform  and  a  moving  train,  a  ureter  was 


INJURIES  OF  THE  URETERS.  173 

ruptured,  the  patient  surviving,  with  other  serious  injuries,  for  135 
hours. 

When  the  fact  cannot  be  demonstrated  to  the  eye,  the  possibility 
of  rupture  of  a  ureter  must  be  judged  of  largely  by  the  nature  of  the 
injury  and  its  attending  circumstances.  In  a  case  reported  by  Dr. 
Collins  where  this  lesion  must  have  occurred,  and  which  is  more  fully 
referred  to  in  connection  with  the  subject  of  traumatic  hydrone- 
phrosis, the  injury  was  caused  by  a  cart-wheel  passing  over  the  abdo- 
men and  pelvis  of  a  child.  The  patient  was  much  collapsed,  there 
was  fracture  of  the  left  lower  ribs  and  right  innominate  bone,  and  the 
catheter  drew  off  only  a  drachm  or  so  of  sanious  fluid.  The  disten- 
tion test  showed  that  the  bladder  was  not  ruptured,  though  the  urine 
was  blood-stained  for  some  days.  The  patient  eventually  developed 
a  right  hydronephrosis.  In  other  cases  a  ruptured  ureter  has  been 
accompanied  by  considerable  lateral  abdominal  distention  extending 
to  the  loin  and  by  slight  hsematuria.  The  effusion  of  a  watery  fluid, 
somewhat  resembling  very  dilute  urine,  in  the  neighborhood  of  the 
injury  has  also  been  noticed  in  several  instances.  In  one  of  those 
cases  recorded  by  Mr.  Stanley  it  is  stated  that  the  fluid  was  found 
to  contain  unequivocal  evidences  of  urea,  and  from  its  appearance 
seemed  to  justify  the  conclusion  that  it  was  of  a  urinous  nature.  In 
the  second  of  Mr.  Stanley's  cases  a  cystic  collection  of  a  somewhat 
similar  fluid  was  found  communicating  with  the  junction  of  the  pel- 
vis of  the  kidney  and  the  ureter,  where  the  injury  had  taken  place. 
In  commenting  upon  these  cases  the  author  observes :  "  They  show  that 
the  rupture  of  the  ureter  or  pelvis  of  the  kidney  may  present  this 
remarkable  feature  when  contrasted  with  the  consequences  of  a  rup- 
ture of  the  bladder :  while  in  cases  of  the  latter  injury  symptoms  im- 
mediately arise,  directly  pointing  to  the  organ  which  has  suffered,  in 
cases  of  the  former  kind  (the  lesion  of  the  ureter  or  pelvis  of  the  kid- 
ney) no  symptoms  may  immediately  arise  leading  to  a  suspicion  of 
injury  to  any  part  of  the  urinary  apparatus." 

In  a  paper  which  deals  very  fully  with  the  subject  of  rupture  of 
the  ureter  Mr.  H.  W.  Page"^  records  an  instance  in  his  own  practice 
where  it  was  extremel}^  probable  that  this  lesion  existed.  A  male  child 
five  years  of  age  was  run  over  by  a  cab  and  sustained  abdominal  in- 
juries, which  were  followed  by  slight  hsematuria  and  the  formation  of 
a  swelling  in  the  right  iliac  fossa.  As  the  symptoms  did  not  im- 
prove and  the  temperature  rose,  about  a  month  after  the  injury  the 
abdomen  was  opened  in  the  right  linea  semilunaris  and  forty  ounces 
of  fluid  were  evacuated  from  a  retro-peritoneal  swelling.  This  fluid 
was  analyzed  and  shown  to  contain  half  its  bulk  or  somewhat  less  of 
normal  urine.     In  spite  of  careful  drainage  a  high  temperature  re- 


174  HAERISON — DISEASES  OP  THE  KIDNEYS  AJSTD  UEETEES. 

turned,  the  discliarge  became  urinous  and  offensive,  and  the  powers  of 
the  patient  began  to  flag.  Two  months  after  the  injury  nephrectomy 
was  performed  and  was  followed  by  complete  recovery.  The  kidney 
was  found  in  an  advanced  state  of  pyelonephritis. 

The  conditions  under  which  a  urinous  effusion  takes  place  some 
days  after  rupture  of  a  ureter  has  occurred  deserve  something  more 
than  a  passing  notice.  One  would  almost  be  inclined  to  suppose 
that  the  escape  of  urine  either  directly  from  the  torn  pelvis  of  the 
kidney  or  from  the  open  ureter  must  be  followed  by  all  the  rapid  and 
disastrous  consequences  which  ensue  when  it  is  effused,  often  in 
conjunction  with  blood,  among  either  normal  or  damaged  tissues. 
The  occurrence  of  these  s^^mptoms  is  certain  and  unmistakable  so 
long  as  no  vent  is  provided  for  urine  which  is  thus  poured  out.  No 
exception  to  this  can  be  brought  forward,  save  in  such  instances  as  I 
shall  presently  illustrate.  Why  this  immunity  from  well-recognized 
consequences  should  exist  in  the  case  of  a  ruptured  ureter,  where  one 
would  naturally  expect  an  extravasation  of  urine  to  follow,  is  a  point 
of  considerable  interest  and  importance. 

In  the  records  of  a  case  with  remarks  by  the  late  Mr.  Poland  and 
Dr.  Moxon  some  light,  I  think,  is  thrown  upon  this  aspect  of  the 
question.  Stress  is  here  laid  on  the  condition  of  the  kidneys  as  ob- 
served in  this  and  other  instances,  it  being  stated  by  Dr.  Moxon  that 
the  vessels  were  blocked  with  ante-mortem  clots.  It  is  almost  im- 
possible to  imagine  that  a  rupture  of  a  ureter  could  be  effected  with- 
out the  application  of  a  considerable  amount  of  violence  to  the  part. 
Even  supposing  that  the  requisite  force  was  limited  to  the  ureter  and 
continued  in  the  form  of  traction  until  the  tube  snapped,  this  would 
almost  necessarily  imply  more  or  less  injury  to  the  corresponding 
kidney.  Is  it  not  likely,  considering  the  sj^mpathies  existing  between 
the  two  kidneys,  that  the  infarcted  condition  of  the  blood-veS"sels  of 
both  organs,  referred  to  by  Dr.  Moxon  as  of  ante-mortem  origin,  is  a 
provision  in  the  first  instance  for  the  substitution  of  a  kind  of  urine 
which  is  incapable  of  proving  destructive  to  the  tissues  with  which 
it  may  come  in  contact?  Thus  time  is  afforded  for  repair,  or  to 
enable  the  opposite  organ  by  a  compensatory  hypertrophy  to  take 
up  the  whole  work  if  necessary. 

This  conclusion  suggested  itself  to  me  in  connection  with  the  fol- 
lowing case.  It  was  one  of  stricture,  with  extravasation  of  urine  into 
the  scrotum,  occurring  in  a  person  suffering  from  Bright's  disease  of 
the  kidneys.  Though  the  extravasation  had  come  on  suddenly  and 
had  existed  for  twenty-four  hours  unrelieved,  there  were  no  signs  of 
acute  inflammatory  action  and  commencing  gangrene,  such  as  are 
usually  expected.       However,  the  tension  being  considerable,  the 


INJURIES  OF'THE  UEETEES.  175 

parts  involved  in  the  extravasation  were  incised.  As  tlie  fluid  es- 
caped from  the  incisions,  it  was  noticed  that  it  had  not  the  strong 
ammoniacal  odor  which  is  so  perceptible  in  such  cases.  I  was  some- 
what puzzled  for  an  explanation,  as  I  felt  sure  that  the  case  was  one 
of  extravasation,  and  not  of  acute  scrotal  oedema.  How  was  it  then 
that  extra vasated  urine  failed  to  create  gangrene?  I  collected  some 
of  the  fluid  as  it  trickled  through  the  wound,  and  compared  it  with 
that  subsequently  drawn  off  by  the  catheter.  They  were  found  to  be 
identical,  and  in  both  there  was  almost  a  complete  absence  of  urea. 
This  then,  to  my  mind,  solved  the  mystery,  and  explained  that,  as 
there  was  no  urea  to  decompose,  there  was  no  source  for  the  produc- 
tion of  the  ammonia  by  which  the  destruction  of  tissues  in  connection 
with  extravasated  normal  urine  is  effected.  By  the  absence  of  urea 
the  urine  was  rendered  chemically  harmless  to  the  tissues  with  which 
it  came  in  contact. 

The  view  I  have  ventured  to  express  as  explaining  certain  points 
connected  with  the  pathology  of  injuries  to  the  ureter  and  pelvis  of 
the  kidney  has  some  weight  given  to  it  by  a  remark  made  by  Mr. 
Holmes  in  connection  with  this  subject :  "  If  it  could  be  shown  that 
a  wound  of  the  ureter  or  a  lesion  of  that  organ  could  suspend  the 
true  secreting  function  of  the  corresponding  kidney,  while  it  left  its 
percolating  function  intact,  or  even  if  any  theoretical  explanation  of 
such  a  result  could  be  given,  the  case  would  be  quite  clear,  since  the 
opposite  kidney  would  have  double  secretive  work  to  do,  and  the 
urine  passed  by  the  urethra  would  be  scanty,  with  excess  of  lith- 
ates." 

The  next  point  to  which  attention  must  be  given  is  the  fact  that, 
as  in  the  case  of  the  urethra,  wounds  and  lacerations  of  the  ureters  are 
liable  to  be  followed  by  dense  and  contractile  strictures.  In  this  way 
the  kidney  may  be  destroyed  either  by  a  process  of  hydronephrosis  as 
previously  referred  to,  or  by  complete  atrophy  and  absorption.  Here 
the  law  of  a  compensatory  hypertrophy  steps  in  and  the  life  of  the 
individual  is  preserved,  although  by  the  necessary  absence  of  one  kid- 
ney it  is  continued  under  conditions  of  living  associated  with  in- 
creased risks,  as  can  readily  be  understood. 

We  have  now  before  us  the  various  contingencies  the  surgeon  has 
to  face  in  connection  with  the  treatment  of  a  rupture  of  a  ureter. 
Putting  aside  complications  involving  neighboring  viscera,  they  may 
be  summed  up  as  collapse,  hemorrhage,  extravasation  of  a  diluted 
and  comparatively  innocuous  urine,  and  the  probabilities,  so  far  as 
the  near  future  is  concerned,  of  a  strictured  if  not  an  impervious 
ureter,  and  a  hydronephrotic  or  atrophied  kidney.  In  view  of  the 
treatment  that  these  conditions  may  require  immediately  or  prospec- 


176  HAKKISON — DISEASES  OF  THE  KIDNEYS  AJSD  IJEETEES. 

tively,  it  will  be  well  to  take  a  glance  at  some  of  the  more  recent  ob- 
servations tliat  have  been  made  bearing  upon  tbis  matter. 

Yan  Hook  "  in  a  valuable  paper  on  tbe  surgery  of  the  ureters  takes 
exception  to  the  performance  of  nephrectomy,  a  practice  which  has 
hitherto  had  ^ome  advocates,  in  cases  where  the  duct  has  been  acci- 
dentally divided,  as,  for  instance,  in  the  course  of  a  laparotomy.  He 
observes  further :  "  Kidneys  are  not  to  be  sacrificed  for  fistulse,  partial 
obstruction  by  valvular  folds  causing  intermittent  hydronephrosis, 
and  strictures  of  the  ureter  that  interfere  to  a  greater  or  less  extent 
with  the  functional  activity  of  the  ducts,  without  exhausting  every 
effort  to  correct  the  morbid  condition." 

This  principle  finds  forcible  and  successful  illustration  in  a  case 
recorded  by  Kiister,"  where,  in  a  boy  who,  by  congenital  defect,  pos- 
sessed but  one  kidney,  a  ureteral  fistula  was  closed  and  the  urine 
compelled  to  traverse  its  natural  channel.  This  was  effected  by  ex- 
posing the  kidney  by  a  posterior  incision.  The  ureter,  on  being 
opened  below  the  sacculated  gland,  disclosed  a  stricture  which  was 
resected  and  the  tube  was  then  implanted  into  the  hydronephrotic 
sac.  A  lumbar  fistula  remained  for  several  months,  but  was  finally 
cured  by  a  secondary  operation. 

The  circumstances  under  which  it  may  be  necessary  for  the  sur- 
geon to  make  an  attempt  by  exploration  to  secure  the  repair  of  one 
of  these  ducts  and  thus  to  avert,  immediately  or  more  remotely,  the 
sacrifice  of  a  kidney,  seem  to  be  limited  to  those  instances  where  the 
evidence  is  reasonably  conclusive  that  the  ureter  is,  or  is  likely  to 
become,  impermeable  to  urine.  In  a  severe  abdominal  injury,  as  a 
crush  or  a  squeeze,  though  there  is  a  possibility  of  such  an  occur- 
rence, the  practitioner  would  hardly  feel  justified  in  proceeding  with 
either  a  lumbar  or  an  abdominal  exploration  on  a  mere  undemonstrated 
suspicion  of  ruptured  ureter,  and  in  the  absence  of  other  lesions  re- 
quiring it. 

A  persistent  hemorrhage  of  apparently  renal  or  ureteral  origin, 
with  or  without  a  cystitis  due  to  retained  blood-clots,  as  in  the  case 
recorded  in  my  account  of  ruptured  kidney,  or  the  presence  of  a  lum- 
bar or  post-peritoneal  swelling  due  to  the  pressure  of  extravasated 
blood  or  pus  in  increasing  amount  or  to  urinous  effusion  or  extrava- 
sation, as  mentioned  in  connection  with  the  symptoms  of  rupture  of 
a  ureter,  either  of  these  would  certainly  more  than  justify  an  explora- 
tion from  the  loin  of  the  kidney  and  its  ureter.  The  latter  are,  as  a 
rule,  outside  the  peritoneum,  and,  in  the  locality  where  ruptures  of 
these  viscera  most  frequently  happen,  an  exploration  is  attended  with 
no  additional  risk.  If  the  ureter  is  discovered  to  be  ruptured  an  at- 
tempt to  effect  its  immediate  repair,  with  the  objects  of  saving  the 


INJURIES   OF  THE  UEETERS.  177 

kidney  and  maintaining  the  eflficiency  of  the  entire  urinary  apparatus, 
would  then  be  entertained. 

Again,  after  a  severe  injury  to  the  side,  when,  though  at  the  time 
it  was  quite  possible  but  not  proved  that  rupture  of  a  ureter  had 
occurred,  the  subsequent  develojjment  of  a  hydronephrosis  would 
warrant  the  exploration  of  the  corresponding  ureter  with  a  view  to 
undertaking  its  repair.  In  illustration  of  this  I  will  mention  a  case 
of  Fenger's  which  is  thus  epitomized  by  Van  Hook:  "Traumatic 
stricture  of  the  ureter  close  to  its  entrance  into  the  pelvis  of  the  kid- 
ney; intermittent  hydronephrosis.  The  patient,  forty-seven  years 
of  age,  had  sustained  an  injury  thirty-four  years  previously.  After 
ten  years  the  hydronephrosis  developed.  Operation  of  lumbar  ne- 
phrotomy disclosed  no  calculi.  The  ureteral  entrance  could  not  be 
found  through  the  renal  opening.  The  dilated  pelvis  was  opened, 
but  still  the  passage  through  the  ureter  could  not  be  discovered. 
The  ureter  was  now  isolated  and  its  upper  end  found  to  be  imbedded 
in  cicatricial  tissue  for  half  an  inch.  Lower  down,  though  small  in 
calibre,  the  duct  was  normal.  A  longitudinal  incision  one  centimetre 
in  length  was  now  made  in  the  ureter  just  below  the  cicatri:^.  The 
stricture  was  one  centimetre  long.  It  was  incised  upward  into  the 
pelvis.  The  ureteral  wound  was  now  stitched  longitudinally,  after  the 
manner  of  the  Heineke-Mikulicz  procedure  for  the  treatment  of  pyloric 
strictures.  No  bougie  was  left  in  place.  The  patient  made  a  good 
recovery  without  return  of  the  hydronephrosis." 

In  the  next  place  an  attempt  to  secure  direct  repair  in  preference 
to  at  once  proceeding  with  a  nephrectomy,  would  be  open  to  the  sur- 
geon, who  in  the  performance  of  an  abdominal  operation  accidentally 
severed  or  wounded  a  ureter.  Several  published  instances  of  this 
accident  in  the  hands  of  competent  operators  v/ill  be  met  with. 

The  possibility  that  a  person  was  born  with,  or  that  circum- 
stances have  brought  about  the  existence  of,  a  single  working  ureter, 
upon  the  integrity  of  which  the  existence  of  the  individual  absolutely 
depended,  must  not  be  lost  sight  of  in  connection  with  severe  abdom- 
inal lesions  where  total  suppression  of  urine  immediately  following 
the  injury  is  a  prominent  feature.  A  ruptured  ureter  might  ac- 
count for  this  and  call  for  a  prompt  exploratory  operation,  otherwise 
a  speedily  fatal  result  would  be  unavoidable. 

Under  such  conditions,  and  possibly  some  others,  the  exploration 
of  a  ureter  may  be  undertaken  with  the  view  of  repairing  it  if  found 
to  be  injured.  We  may  now  proceed  to  notice  in  detail  the  modes 
which  have  been  adopted  to  secure  the  continuity  of  so  small  a  tube. 

Van  Hook  thus  refers  to  observations  on  several  points  connected 
with  the  ureters  (in  woman)  which  he  considers  are  not  correctly  or 
Vol.  I.— 13 


178  HAEKISON — DISEASES  OF  THE  KEDKEYS  AJSTD  URETERS. 

fully  stated  in  some  text-books :  "  Upon  examining  the  ureters  of  over 
twenty  bodies  he  never  found  one  over  fifteen  inches  long,  the  average 
being  between  ten  and  twelve  inches  in  length.  The  ureter  when 
stripped  from  the  peritoneum  may  be  drawn  out  from  two  to  four 
inches.  The  cui^vature  of  the  abdominal  ureter  has  its  convexity  di- 
rected inward,  while  the  convexity  of  the  pelvic  portion  is  turned  out- 
ward. The  pelvic  portion  of  the  ureter  describes  a  very  strong  curve, 
almost  the  arc  of  a  circle,  since  the  duct  hugs  the  bony  wall  of  the  pel- 
vis very  closely.  Hence  the  portion  of  the  ureter  opposite  the  uterus 
is  at  some  distance  from  that  organ,  and  as  the  ureter  approaches 
the  base  of  the  bladder  (which  it  enters  at  a  point  near  the  middle  of 
the  distance  between  the  urinary  meatus  and  the  cervix) ,  it  curves 
rather  sharply  forward  and  inward,  so  that  the  point  in  the  duct 
nearest  the  cervix  is  below  and  behind  the  posterior  lip.  It  must  not 
be  forgotten  that  the  ureter  has  three  points  of  diminution  of  calibre 
which  may  give  rise  to  mistakes  in  the  search  for  pathologic  stenoses. 
The  first  is  between  one  and  a  half  and  two  and  a  half  inches  from 
the  pelvis  of  the  kidney,  according  to  Dr.  Tanquary'^s  measurements. 
The  second  is  at  the  junction  of  the  pehdc  and  vesical  portions.  The 
third  when  present  (found  in  three  out  of  five  subjects)  is  just  where 
the  ureter  crosses  the  iliac  artery." 

Referring  to  the  modes  of  approaching  the  ureters  for  surgical 
purposes  the  same  author  observes:  "The  extra-pelvic  portion  of 
the  ureter  is  most  readily  and  safely  accessible  for  exploration  and 
surgical  treatment  by  the  retro-peritoneal  route.  Hence  all  opera- 
tions upon  the  ureters  above  the  crossing  of  the  iliac  arteries  should 
be  performed  retro-peritoneally,  excepting  those  cases  in  which  the 
necessity  for  the  ureteral  operation  arises  during  laparotomy.  The 
intra-pelvic  portion  may  be  reached  by  incision  through  the  ventral 
wall,  the  bladder,  the  rectum,  the  vagina  in  the  female,  the  perineum 
in  the  male,  or  by  Kraske's  sacral  method." 

The  processes  of  dealing  with  a  wounded  or  a  stenosed  ureter 
may  be  described  as  (1)  by  suture,  and  (2)  by  external  or  internal 
implantation,  the  former  being  sometimes  utilized  for  merely  tempo- 
rary purposes. 

There  seems  very  little  doubt  that,  as  in  the  case  of  the  urethra, 
longitudinal  wounds  of  the  ureter,  pro^dded  only  the  drainage  is 
sufficient,  heal  spontaneously  without  causing  subsequent  contrac- 
tion. This  is  evident  as  the  result  of  experiments  on  animals  as  well 
from  what  has  followed  accidental  incisions,  or  those  made  into  these 
tubes  for  the  removal  of  calculi.  And  the  same  degree  of  treatment 
is  applicable  to  those  cases  where  the  wound  takes  a  transverse  direc- 
tion though  it  fails  in  effecting  a  complete  severance  of  the  ureter; 


INJURIES  OP  THE  URETERS.  179 

SO  long  as  the  drainage  is  free,  kindly  and  complete  repair  may  be  an- 
ticipated witliout  interference.  In  extensive  transverse  wounds  of  tlie 
ureter  involving  more  than  one-third  of  the  thickness  of  the  tube 
Van  Hook  concludes  "  that  stricture  by  subsequent  scar  contraction 
should  be  anticij)ated  by  converting  the  transverse  into  a  longitudinal 
wound  and  introducing  longitudinal  sutures."  The  technique  is  thus 
described :  "  Make  two  longitudinal  incisions  with  small  scissors  in 
the  ureter  beginning  at  the  middle  of  the  wound  to  be  closed.  These 
incisions  should  be  equal  in  combined  length  to  twice  the  transverse 
diameter  of  the  tube.  Bound  off  the  sharp  angles  of  tissue  with  the 
scissors  and  suture  longitudinally  with  the  object  of  producing  a 
very  wide  instead  of  a  very  contracted  lumen." 

The  second  method  of  dealing  directly  with  wounds  of  the  ureters 
is  by  "implantation,"  of  which  there  are  several  varieties  arising  out 
of  the  difference  in  location  of  the  injury.  To  implant  a  ureter  into 
an  isolated  knuckle  of  bowel  is  found  to  be  objectionable  on  the 
grounds  that  the  operation  is  in  itself  too  dangerous  and  the  intes- 
tine is  not  aseptic.  The  certainty  with  which  a  kidney  may  be  thus 
infected  by  means  of  the  intestinal  gases  has  proved  an  obstacle  in  at- 
tempts which  have  been  made  in  cases  of  extroversion  of  the  bladder 
to  dispose  of  the  urine  in  this  manner.  In  injuries  to  the  pelvic 
ureter  during  laparotomy,  where  the  continuity  cannot  be  restored  or 
temporary  vaginal  implantation  effected  in  the  female,  or  vesical  im- 
plantation in  the  male,  Van  Hook  advises  that  the  proximal  extremity 
of  the  duct  should  be  fastened  to  the  skin  at  the  nearest  point  to  the 
bladder.  In  injuries  to  its  upper  or  lower  end,  the  ureter  may 
be  implanted  into  the  pelvis  of  the  kidney  or  into  the  bladder  re- 
spectively. 

Dr.  Abbe  *"  reports  a  case  of  ruptured  ureter  of  an  unusual  kind. 
It  happened  in  an  instance  of  an  exploratory  operation  on  a  man,  by 
means  of  Kraske's  operation,  for  what  was  supposed  to  be  either  an 
abscess  between  the  bladder  and  the  rectum,  or  a  vesical  pouch. 
During  the  manipulation  a  ureter  was  torn  across.  The  sac  proving 
to  be  a  vesical  pouch  the  ureter  was  implanted  into  the  bottom  of  it 
and  secured  by  sutures.  The  wound  healed  and  the  pouch  shrank. 
Dr.  Abbe  believed  the  patient  would  be  permanently  cured,  as  in 
this  way  the  sac  was  kept  flushed  by  healthy  urine.  This  may 
further  be  regarded  as  a  contribution  to  the  treatment  of  vesical  sac- 
culation or  pouching. 

It  should  be  stated  that  a  case  has  recently  been  published  which 
is  at  variance  with  the  view  that  the  insertion  of  a  ureter  into  a  viscus 
is  objectionable  on  the  ground  that  the  corresponding  kidney  is  likely 
to  become  diseased  through  contact  with  septic  gases.     Chaput^"  re- 


180  HAEEISON — DISEASES  OF  THE  KEDNEYS  AND  URETERS. 

cords  one  successful  case,  as  well  as  a  fatal  one,  wliere  an  unilateral 
uretero-intestinal  anastomosis  was  established  in  a  case  of  uretero- 
vaginal  fistula.  Tlie  ureter  was  exposed  by  an  incision  in  tlie  left 
iliac  fossa  and  tlie  peritoneal  cavity  was  opened.  The  paper  contains 
an  interesting  summary  of  the  literature  of  this  aspect  of  the  subject, 

though  it  does  not  negative  the 
objections  to  the  practice  I 
have  stated. 


\ 


/        ^'^^s^Jj^  v^  '  < —       In  complete  transverse  divi- 

^  \  sion  of  the  ureter  in  its  con- 

FiG.  29.— Traction  Sutures  in  Place.  These  sutures  tiuuitv  it  SeemS  likely  that  Van 
pass  through  the  posterior  wall  of  the  ureter  but  ^^^^'^  method  of  UuioU  by 
once.  .  "^ 

what  he  calls  "  lateral  implanta- 
tion" will  be  found  of  practical  value.  It  consists  in  ligaturing  the 
free  end  of  the  lower  portion  of  the  tube,  about  one-eighth  of  an 
inch  from  its  divided  extremity,  with  silk  or  catgut;  then  below 
this  point  opening  the  tube  longitudinally  to  an  extent  sufficient 
to  receive  the  corresponding  end  of  the  upper  portion  of  the  ureter, 
which  is  drawn  into,  and  retained  in,  this  position  by  fine  sutures. 
The  mode  of  effecting  this  is  shown  by  illustrations  (Tigs.  29,  30,  and. 
31)  in  a  paper  on  uretero-ureteral  an- 
astomosis by  Dr.  Howard  A.  Kelly  ,^  -j,,^ 
i  the  Annals  of  Surgery,  January,  ""  '"'""j^^^ 
1894. 

Van  Hook  thus  describes  a  meth-    Fig.  30.— ureter  Anastomosed.    The  traction 

sutures  are  hid  and  the  two  flxat 
tures  are  in  place  ready  to  be  tied. 


Y 


od  of  dealing  with  a  wounded  ureter     ^^*"'^'^^  ^'^  ^'^  ^"""^  *^«  two  fixation 


of  a  very  ingenious  character  which 
was  first  suggested  by  Ludwig  Eydygier.  I  am  not,  however,  aware 
that  it  has  hitherto  been  successfully  practised :  "  He  advises  that 
in  cases  of  injury  to  the  ureter  during  surgical  operations  the  two 
ends  of  the  ureter  be  brought  out  through  the  abdominal  waU  and 
the  wall  be  allowed  to  close  about  them.  He  would  then  prepare  for 
the  urine  an  artificial  channel  of  skin  by  making  two  parallel  in- 
cisions between  the  two  openings,   suturing    together  the  edges  of 

the   isolated   piece  of   skin   so  as 
to  form  a    tube,    and   depressing 
^  this  tube  by   sewing   over  it  the 
severed  edges  of  skin  drawn  from 

Fig.  31.— Longitudinal  Section  of  the  Ureter,     each     side."      The     changes    which 
Showing  New  Lumen  and  Diverticulum.  ^^^^   ^j^^^     -^    ^^^     j^.^^^^     ^^^g^, 

quent  on  an  impermeable  or  strictured  ureter  have  already  been  re- 
ferred to  in  connection  with  the  subject  of  surgical  disorders  of  the 
kidneys. 


OBSTRUCTION  OP  THE  URETERS.  181 


Obstruction  of  the  Ureters. 

I  have  ah'eady  discussed  how  a  ureter  may  be  obstructed  by  a 
cicatrix  following  upon  a  wound  as  happens  so  frequently  in  the  anal- 
ogous case  of  the  male  urethra,  the  effects  that  may  be  thus  pro- 
duced in  the  kidney,  and  upon  what  principles  the  surgeon  may  pro- 
ceed in  the  treatment  of  such  a  lesion.  I  will  pass  on  to  notice  in 
what  other  ways  the  function  of  these  tubes  may  be  interfered  with. 

That  a  fatal  result  may  suddenly  be  brought  about  by  an  obstruc- 
tion of  the  ureter  there  can  be  no  doubt.  Dr.  Fuller  ^^  records  a 
case  of  this  kind  where  a  pyonephrotic  kidney  burst  into  the  abdom- 
inal cavity,  causing  death  by  acute  peritonitis.  The  ureter  was  found 
impacted  with  renal  calculi. 

The  question  has  been  raised  in  a  paper  by  Mr.  W.  G.  Nash," 
based  on  a  preparation  of  strictured  ureter  in  the  Museum  of  St.  Bar- 
tholomew's Hospital  (No.  2361  A),  as  to  whether  such  a  contraction 
can  be  caused  by  the  extension  of  a  gonorrhoeal  inflammation  to  these 
tubes.  If  it  were  so,  I  think  that  we  should  meet  with  instances  of  this 
kind  more  frequently,  and  consequently  that  hydronephrosis  and 
pyonephrosis  would  oftener  require  surgical  relief.  Still,  having  re- 
gard to  the  distance  that  this  specific  inflammation  sometimes  travels, 
as,  for  instance,  in  the  female,  I  should  not  like  entirely  to  put  aside 
its  possibility  under  the  circumstances  referred  to. 

That  a  stricture  of  a  ureter  may  be  caused  by  the  cicatrix  resulting 
from  the  ulceration  produced  by  its  temporary  impaction  by  a  stone, 
as  well  as  by  the  scar  following  the  healing  of  a  tuberculous  abrasion, 
there  can,  I  think,  be  no  doubt. 

Notwithstanding  that  operations  on  the  vesical  openings  of  the 
ureters,  either  for  catheterizing  these  tubes  in  the  male  or  for  drain- 
ing them  directly,  would  no  doubt  be  now  done  through  the  medium 
of  a  supra-pubic  opening,  the  following  observations,  which  I  made 
some  years  ago  on  the  dead  subject,  with  the  assistance  of  Dr.  Bar- 
ron, may  still  find  a  place.  Lateral  lithotomy  was  performed  on  a 
middle-aged  healthy  male  cadaver ;  the  incision  into  the  bladder  was 
extended  in  front  by  opening  into  the  membranous  urethra  with  a 
probe-pointed  bistoury,  and  behind  by  cautiously  extending  the  cut 
into  the  prostate  to  almost  its  extreme  boundary.  On  subsequently 
removing  the  parts,  it  was  found  that  in  this  way  a  considerable 
opening  could  be  made  into  the  bladder  without  exceeding  what  I 
should  regard  as  a  safe  limit.  Though  the  opening  just  described 
permitted  a  free  access  to  the  bladder  for  the  finger,  yet  no  part  of 
the  mucous  lining  of  the  viscus  could  be  inspected  even  with  the  em- 


182  HAERISON — DISEASES  OF  THE  KIDNEYS  AND  UEETEES. 

ployment  of  retractors.  With  tlie  latter,  aided  by  forcible  pressure 
downward  with  tlie  hand  over  the  pubes,  a  small  portion  of  the  fundus 
of  the  bladder  could  be  brought  within  sight,  but  the  orifices  of  the 
ureters  could  not  be  seen,  nor  could  any  instrument,  such  as  a  probe 
introduced  into  the  bladder  through  the  wound,  be  made  to  enter  them. 
The  cavity  of  the  abdomen  was  then  opened  by  a  median  incision 
above  the  pubes  sufficient  to  permit  of  the  introduction  of  three  fin- 
gers over  the  fundus  of  the  bladder.  By  thus  pressing  the  bladder 
down  toward  the  perineal  wound,  the  whole  of  its  mucous  surface 
could  be  brought  into  view,  including  the  orifices  of  the  ureters  and 
the  trigone.  In  one  subject,  by  reason  of  some  enlargement  of  the 
prostate,  the  view  of  the  latter  was  imperfect.  With  the  object  of 
improving  this,  an  endeavor  was  made  to  elevate  the  parts  by  the 
introduction  of  (1)  two  fingers  up  the  rectum;  (2)  a  lever,  (3)  the 
whole  hand  passed  into  the  rectum.  By  the  first  two  methods  the 
view  of  the  trigone  was  not  improved,  while  the  hand  in  the  bowel, 
by  occupying  the  whole  space,  obscured  everything.  When,  how- 
ever, there  was  no  enlargement  of  the  prostate,  it  was  found  possible, 
with  the  hand  introduced  into  the  abdomen,  to  bring  all  parts  of  the 
mucous  surface  of  the  bladder  into  sight,  including  that  immediately 
behind  the  pubes.  It  was  found  easy  to  catheterize  the  left  ureter, 
but  the  right  required  a  little  more  looking  for.  By  a  bilateral  sec- 
tion of  the  x)rostate  the  search  for  the  latter  was  facilitated,  but  the 
conclusion  we  came  to  was  that  with  a  natural  prostate  this  addi- 
tional incision  was  not  necessary.  It  seemed  not  only  possible  to 
bring  the  whole  of  the  mucous  membrane  of  the  bladder  into  view 
and  within  reach  of  manipulation,  and  to  catheterize  the  ureters,  but, 
further,  with  the  hand  in  the  abdomen  to  command  all  hemorrhage 
from  the  parts  through  which  the  deeper  incision  would  probably 
pass.  In  a  case  I  saw  operated  on  by  Mr.  Eushton  Parker,  where 
the  prostate  was  incised  more  freely  than  is  usual,  a  circumstance 
which  probably  arose  from  the  form  of  the  calculus,  almost  the  whole 
of  the  mucous  membrane  of  the  bladder  could  be  readily  seen,  includ- 
ing the  orifices  of  the  ureters,  which  might  have  easily  been  catheter- 
ized.  The  patient  was  a  boy,  aged  about  twelve  years,  who  made  a 
good  recovery. 

Various  means  have  been  adopted  for  collecting  the  urine  as  it 
escapes  from  each  ureter  into  the  bladder.  One  of  these  consists  in 
the  employment  of  ureteral  catheters,  and  another  in  the  compression 
of  one  of  the  tubes  and  the  examination  then  of  what  escapes  from 
the  opposite  kidney.  I  cannot  say  that  either  of  them  is  generally 
practical.  A  reference  has  been  made  to  this  means  of  diagnosis  in 
the  section  on  the  surgery  of  the  kidney. 


OBSTEUCTION  OP  THE  URETERS.  183 

The  most  frequent  form  of  obstruction  in  one  or  both,  ureters  un- 
doubtedly is  that  produced  by  the  impaction  of  calculi  in  their  tran- 
sit from  the  kidney  to  the  bladder.  In  cases  where  the  urinary  ap- 
paratus is  normally  disposed,  apart  from  the  symptoms  indicating 
this,  such  an  occurrence  may  bring  about,  when  one  ureter  is  in- 
volved, the  ultimate  destruction  of  the  corresponding  kidney,  or  when 
both  tubes  are  similarly  implicated,  the  speedy  death  of  the  individ- 
ual from  what  has  been  called  obstructive  or  mechanical  suppression 
of  urine.  In  cases  of  the  latter  the  course  of  events  as  gathered  from 
records,  as  weU.  as  from  some  instances  I  have  met  with,  is  usually 
this : 

There  is  a  bygone  history  of  one  or  more  attacks  of  renal  colic, 
followed,  perhaps,  by  the  escape  of  kidney  calculi.  The  recollection 
of  a  paroxysm  of  nephralgia  where  no  stone  was  passed  may  be  sig- 
nificant. During  one  of  these  occasions,  however,  a  stone  becomes 
impacted  in  the  ureter,  and  the  corresponding  kidney  is  eventually 
destroyed  by  absorption  or  disintegration.  In  the  lapse  of  time  the 
opposite  organ  undergoes  a  compensatory  hypertrophy  and  the  entire 
excretion  of  urine  is  thus  provided  for.  So  far  all  this  might  happen 
without  necessarily  exciting  much  attention ;  the  symptoms  of  renal 
colic  disappear  as  the  calculus  is  rendered  immobile  in  the  ureter, 
blood  ceases  to  be  found  in  the  urine,  and  ultimately  the  fact  that  the 
patient  has  gradually  lost  a  kidney  fails  to  be  apparent.  In  time, 
however,  the  enlarged  remaining  kidney  becomes  the  seat  of  stone 
formation  as  in  the  former  case  of  the  lost  organ,  and  again  a  renal 
calculus  becomes  firmly  fixed  in  its  ureter.  This  of  course  neces- 
sarily means  a  more  or  less  complete  suppression  of  urine  according 
to  the  position  occupied  by  the  stone  in  the  ureter.  The  fact  may 
be  briefly  stated  that  one  kidney  has  already  been  destroyed  and  the 
other  is  now  blocked  mechanically.  When  the  whole  history  of  a 
case  of  this  nature  is  reviewed  and  summed  up,  there  can  be  but  little 
difficulty  in  coming  to  a  conclusion  as  to  what  has  occurred. 

Let  me  illustrate  the  pathological  details  of  a  case  of  this  kind 
from  some  well-authenticated  source.  Sir  William  Roberts  records 
the  following  account  of  the  post-mortem  findings  in  a  case  where  an 
obstructive  suppression  of  urine  had  proved  fatal  in  the  course  of 
nine  days  and  a  haH : 

"Autopsy:  Strong  rigor  mortis;  body  well  nourished  and  quite 
free  from  urinous  or  ammoniacal  odor.  All  the  organs  healthy  ex- 
cept the  kidneys  and  ureters.  The  right  kidney  was  wholly  converted 
into  a  fibrous  mass,  studded  with  cysts,  and  weighed  two  and  a  half 
ounces.  The  corresponding  ureter  was  im])ervious  throughout,  and 
changed  io  a  fibrous  cord,  which  was  thickened  about  the  middle  to 


184  HAEEISON — ^DISEASES  OF  THE  KIDNEYS  AND  tlEETEES. 

double  its  widtli.  This  tliickened  part  was  solid  and  fibrous  like  the 
rest.  No  stone  existed  in  any  part  of  tlie  ureter  or  kidney,  but  it 
was  conjectured  that  the  thickened  part  of  the  ureter  had  been  the 
seat  of  an  obstruction,  and  that  the  stone,  or  whatever  object  had 
constituted  the  obstruction,  had  been  subsequently  removed  by  ab- 
sorption. The  left  kidney  was  much  enlarged,  it  weighed  ten  ounces, 
and,  on  section,  appeared  dark  and  intensely  congested.  The  ureter 
was  as  thick  as  a  goose-quill,  and  distended  with  urine.  At  its  lower 
part  were  found  three  little  oxalate-of-lime  calculi  about  the  size  of 
hemp-seeds,  and  weighing  altogether  about  one  and  a  half  grains. 
One  of  these  was  tightly  impacted  in  the  terminal  part  of  the  ureter, 
where  it  passes  through  the  coats  of  the  bladder ;  this  was  the  cause 
of  the  obstruction.  The  fluid  imprisoned  in  the  ureter  amounted  to 
three  drachms,  and  consisted  of  grumous  bloody  urine.  The  pelvis 
of  the  kidney  was  only  slightly  dilated,  and  contained  about  two 
drachms  of  bloody  urine.  The  bladder  contained  about  six  ounces 
of  pale  dilute  urine ;  its  coats  were  healthy. " 

That  cases  of  this  kind  and  others  which  might  be  mentioned 
should  have  directed  the  attention  of  surgeons  to  the  matter  is  not 
surprising.  The  occurrence  of  death  from  a  comparatively  slight 
and  so  removable  a  cause  as  I  have  just  illustrated  would  hardly  be 
likely  to  pass  without  comment  in  these  days,  when  so  many  of  the 
difficulties  connected  with  exploratory  surgery  are  now  removed  by 
anaesthetics  and  antiseptics.  I  will  proceed  to  notice  the  practical 
aspect  of  such  a  reflection,  and  will  do  so  more  by  illustration 
than  by  generalizing. 

As  I  have  already  stated,  in  the  normal  disposition  of  the  parts 
the  fact  that  a  stone  has  become  impacted  in  a  ureter  and  is  leading 
up  to  the  absorption  or  destruction  of  the  corresponding  kidney  may 
easily  pass  by  without  recognition.  Such  a  case"'  is  recorded  by 
Mr.  Canton.  On  the  other  hand,  this  circumstance  may  declare  it- 
seK  by  symptoms  which  in  themselves  are  sufficient  to  demand  surgi- 
cal interference  for  their  relief  without  regard  to  the  important  issue 
at  stake  so  far  as  the  future  of  the  kidney  is  concerned. 

What  signs  then  would  lead  to  the  belief  that  one  of  the  two  nor- 
mal ureters  is  impacted  with  a  stone?  Under  what  circumstances 
should  an  attempt  be  made  surgically  to  effect  the  removal  of  the 
calculus,  and  lastly,  what  kinds  of  procedure  may  thus  be  under- 
taken? 

It  may  be  generally  stated  that  a  stone  may  be  impacted  in  any 
part  of  a  normal  ureter ;  but  by  reason  of  its  relations  the  liability 
to  fixation  is  greatest  where  the  tube  enters  the  bladder.  The  diffi- 
culty of  determining  whether  a  calculus  has  left  the  kidney  and  is 
still  retained  in  the  ureter  is  sometimes  great.  Usually  the  symp- 
toms of  the  latter  are  less  urgent.     If,  after  renal  colic  limited  to  one 


OBSTRUCTION  OF  THE  URETEES.  185 

side  and  attended  with  hsematuria,  tlie  pain  becomes  more  fixed,  less 
acute,  and  pressure  with,  the  grasp  of  the  hand  refers  it  to  a  precise 
area  nearer  the  groin,  while  at  the  same  time  the  presence  of  blood 
in  the  urine  either  entirely  or  in  a  great  measure  ceases,  the  prob- 
ability that  the  calculus  is  retained  in  the  ureter  is  considerable. 
Relative  to  hgematuria,  a  stone  fixed  in  the  ureter  will  often  act  the 
part  of  a  ligature.  Of  course  where  one  kidney  and  its  ureter  are 
uninvolved  in  the  calculous  trouble,  the  question  of  suppression  can- 
not arise. 

Amongst  the  more  remarkable  instances  of  calculus  impacted  in 
the  ureter  is  one  I  had  the  opportunity  of  seeing  with  Dr.  Rawdon, 
where  the  stone  was  felt  by  the  finger  in  the  rectum.  The  following 
are  notes  of  the  case : 

Case. — T.  F.,  a  male,  aged  six,  was  admitted  into  the  Liverpool 
Infirmary  for  Children  on  September  20th,  1878,  suffering  from  stone 
in  the  bladder.  Lateral  lithotomy  was  performed,  and  portions  of  a 
phosphatic  calculus  were  removed.  On  the  twentieth  day  no  urine 
was  passed  for  six  hours  and  shortly  after  he  complained  of  pain  low 
down  on  the  left  side,  which  was  followed  by  a  rigor.  Under  chloro- 
form the  bladder  was  explored,  but  nothing  was  discovered  to  account 
for  these  symptoms.  The  rectum  was  then  examined'  by  the  finger, 
when  a  solid  body  was  felt,  which  was  diagnosed  to  be  a  calculus  in 
the  left  ureter.  The  patient  gradually  sank.  Autopsy :  The  right 
kidney  was  healthy  but  hypertrophied,  being  a  third  over  the  nor- 
mal size.  The  ureter  was  natural.  The  left  kidney  was  atrophied, 
being  one-third  under  normal,  though  the  pelvis  and  calyces  were 
dilated.  The  left  ureter  was  dilated  and  impacted  with  two  calculi. 
The  larger  stone  which  was  felt  from  the  rectum  during  life,  resem- 
bled a  date-stone,  and  was  close  above  the  vesical  opening  of  the 
ureter. 

As  with  vesical  calculi,  the  continuance  of  symptoms  both  distress- 
ing and  hurtful  to  the  patient  and  apparently  irremediable  by  medi- 
cines would  point  to  the  adoption  of  some  exploratory  measures 
which  might  permit  of  the  removal  of  the  stone  if  discovered.  If  the 
symptoms  did  not  indicate  otherwise,  I  should  in  the  first  instance 
proceed  to  expose  the  peltis  of  the  kidney  and  the  upper  portion  of 
the  ureter  by  an  incision  from  the  loin,  and  then,  if  no  stone  is  de- 
tected, to  open  the  pelvis  of  the  kidney,  and  to  exjolore  the  whole 
length  of  the  ureter  by  the  introduction  of  a  ureteral  bougie.  A  long 
flexible  instrument  with  a  slightly  bulbous  extremity  and  of  about  a 
number  11  or  12,  French  size,  should  be  used  for  this  purpose.  In 
this  way  calculi  have  been  removed,  or  carried  on  into  the  bladder, 
while  in  other  instances,  though  the  latter  has  not  been  accomplished, 
the  position  of.  the  obstruction  has  been  localized  and  its  subsequent 
extirpation  by  a  secondary  operation,  more  adapted  to  the  position 


186  HAERISON — DISEASES  OF  THE  KIDNEYS  AND  URETEES. 

of  the  stone,  effected.  For  an  investigation  of  tliis  kind  tlie  use  of 
tlie  electric  cystoscope  sliould  not  be  overlooked;  it  is  often  quite 
possible  by  this  apparatus  to  distinguish,  between  a  working  and  an 
inoperative  ureter  whatever  the  cause  of  the  latter  may  be.  The  in- 
jection of  water  into  the  bladder  so  as  to  distend  it  has  also  brought 
about  relief  to  the  obstruction,  as  I  have  elsewhere  stated.  ^° 

In  reference  to  the  latter  suggestion  it  may  be  thought  that  the 
mode  in  which  the  ureters  enter  the  bladder  is  opposed  to  the  possi- 
bility of  fluid  injected  into  the  viscus  gaining  access  to  these  tubes. 
This,  however,  is  not  invariably  the  case.  In  an  instance  recorded  by 
Mr.  Godlee, "  it  is  observed,  "  though  the  stone  was  impacted  half-way 
down  the  ureter  the  tube  was  dilated  throughout  its  extent."  Doubt- 
less this  was  due  to  the  passage  of  previous  calculi.  Again  Dr.  Daw- 
son WilUams'''"  has  remarked  that  "  pressure  on  the  bladder  caused 
regurgitation  into  the  ureters  and  pelvis."  I  myself  have  known 
instances  where  after  a  vesical  distention  and  palpation  with  the  hand 
over  the  pubes  renal  calculi  were  almost  immediately  expelled. 

Among  instances  of  unilateral  obstruction  of  the  ureter  where 
the  calculus  was  successfully  removed  by  operation  are  two  narrated 
by  Mr.  Cotterell,"  both  of  which  occurred  in  females.  In  the  first 
case  it  is  stated :  "  Ureter  explored  by  incision  similar  to  that  de- 
scribed for  tying  the  common  iliac  artery.  Calculus  found  impacted 
just  below  the  brim  of  the  pelvis.  The  ureter  was  not  sutured."  In 
the  second  instance  it  is  recorded :  "  Exploration  of  bladder  by  the 
urethra  detected  two  calculi  lodged  in  lower  end  of  right  ureter  not 
projecting  into  the  bladder.  They  were  removed  by  incising  the 
ureter  through  the  vault  of  the  vagina. "  Mr.  G.  Twynam"  also  reports 
the  removal  of  a  stone  from  the  ureter  of  a  child  eight  years  of  age 
by  an  operation  similar  to  that  adopted  for  tying  the  common  iliac 
artery.  The  wound  was  closed  with  fine  silk.  On  the  fifth  day  the 
urine  ceased  to  flow  from  the  wound,  and  the  boy  made  a  good  recov- 
ery. The  stone  weighed  six  grains.  Mr.  W.  Lane '"  records  a  case 
where  a  calculus  was  removed  from  the  ureter  of  a  woman  by  abdom- 
inal section  after  a  futile  attempt  had  previously  been  made  by  a 
lumbar  incision.  The  abdomen  was  opened  along  the  left  linea  semi- 
lunaris, and  in  the  portion  of  the  ureter  which  had  not  been  explored 
at  the  earlier  operation  a  small  stone  was  felt.  This  was  forced  up- 
ward along  the  ureter  to  the  crest  of  the  ilium,  and  by  means  of  a 
small  incision  the  stone  was  removed.  The  aperture  in  the  ureter 
was  closed  with  a  fine  suture,  and  healing  took  place  without  urine 
leakage. 

Dr.  R.  Morison  ^^  relates  the  particulars  of  a  case  in  a  man  aged 
thirty-one,  where  a  stone  was   impacted  in  the  ureter  about  three 


OBSTRUCTION  OF  THE  URETERS.  187 

inclies  from  the  kidney.  A  lumbar  exploration  was  made  and  the 
kidney  drawn  out  on  the  loin  and  opened.  As  no  stone  was  discov- 
ered in  this  position  a  long  probe  was  passed  down  the  ureter,  when 
the  calculus  was  felt  and  removed  by  incision.  The  ureter  was  not 
sutured.  Though  a  troublesome  sinus  remained  some  time,  recovery 
was  complete. 

Mr.  Barker  "  relates  a  case  where,  after  he  had  removed  a  stone 
from  the  upper  part  of  the  ureter,  the  pain  returned  by  reason  of  the 
ureter  being  strictured  from  the  effects  of  the  stone.  That  the  ureter 
though  contracted  was  pervious  was  evident  from  the  injection  of  milk 
into  it,  which  escaped  by  the  bladder.  The  patient  was  perfectly 
relieved  by  having  a  permanent  fistula  in  the  loin.  Dr.  Cabot "  also 
reports  two  successful  cases  of  uretero-lithotomy,  one  treated  by 
incision  through  the  loin,  and  the  other,  where  the  stone  had  previ- 
ously been  felt  from  the  vagina  close  to  the  cervix  uteri,  by  an  inci- 
sion through  the  vault  of  the  vagina.  The  latter  stone  weighed  190 
grains,  and  its  removal  was  followed  by  a  gush  of  pus  from  above. 

Mr.  Henry  Morris  "^  has  drawn  attention  to  the  feasibility  of  re- 
moving calculi  impacted  in  the  lower  end  of  the  ureter  by  perineal 
urethrotomy  in  the  male,  or  by  dilatation  of  the  urethra .  in  the  fe- 
male, and  relates  a  case  where  such  a  proceeding 
would   probably  have   been  successful.     After  the 
bladder  has  been  reached  with  the  finger  and  ex-     fig.  32.— ureteral 
plored,  the  use  of  a  scoop  is  suggested.     In  some  caicuius. 

instances  where  the  prostate  is  very  large  a  supra-pubic  exploration 
might  be  preferable. 

By  the  use  of  the  sound  and  the  lithotrite  I  have  dislodged  calculi 
which  it  is  believed  were  retained  in  the  orifices  of  the  ureters.  The 
figure  represents  a  specimen  (Fig.  32)  which  was  spontaneously  dis- 
charged after  I  had  examined  the  bladder  with  a  sound.  There  is  a 
little  groove  on  the  side  of  the  stone  which  prevented  the  ureter  being 
completely  occluded. 

Passing  to  cases  of  obstructive  suppression  of  urine,  where  one 
kidney  either  is  congenitally  absent  or  has  been  destroyed,  possibly 
almost  quiescently,  by  a  calculous  occlusion  of  its  ureter,  the  patient's 
condition  is  a  very  serious  one  unless  the  ureter  can  be  rendered  per- 
meable, or  a  renal  fistula  be  established. 

There  are  many  suggestive  points  of  interest  and  practical  value 
in  connection  with  these  forms  of  mechanical  suppression.  The 
urine  is  usually  of  very  low  specific  gravity  and  deficient  in  urea. 
Sir  William  Roberts  states  that  when  suppression  is  complete  the 
duration  of  life  fi,j)pears  to  range  from  nine  to  eleven  days.  Sir 
James  Paget  "'■'  records  a  case  where  tliere  was  total  suppression  for 


188       '        HAEEISON — DISEASES  OF  THE  KIDNEYS  AMD  URETEES. 

twenty-one  days  only  interrupted  by  one  day's  emission  of  urine. 
The  late  Dr.  Moxon  referred  to  an  instance  wliere  suppression  ex- 
isted for  fourteen  days,  wlien  the  patient  voided  a  calculus  and  recov- 
ered. Hence  a  certain  time  for  action  is  allowed  in  cases  of  this  kind 
so  that  operative  interference  need  not  necessarily  be  too  precipitate. 
On  the  other  hand,  this  fact  should  not  be  construed  as  warranting  a 
needless  and  dangerous  delay. 

Occasionally  the  suppression  is  not  absolutely  complete,  and  in- 
termissions when  urine  is  discharged  may  occur.  The  latter  circum- 
stances are  sometimes  apt  to  be  misleading,  and  are  probably  due  to 
the  calculus  not  fitting  the  interior  of  the  ureter  precisely,  or  to  its 
being  slightly  grooved  or  hollowed  out  as  in  the  case  of  a  stone  which 
is  figured  in  a  preceding  paragraph.  These  urine  leakages  must 
not,  however,  be  allowed  to  distract  attention,  until  it  is  too  late, 
from  the  main  issue.  If  the  greater  bulk  of  the  urine  is  unable  to 
escape  from  the  body  by  some  channel,  ursemic  poisoning  and  death 
cannot  be  long  postponed.  Assisting  by  medicines  and  nutriments 
a  partially  disabled  kidney  where  the  secretion  is  naturally  voided, 
is  a  widely  different  matter  from  aiding  a  healthy  organ  whose  ex- 
cretory duct  is  as  effectually  sealed  as  if  it  were  constricted  by  a 
ligature.  Such  natural  reflections  as  these  cannot  be  allowed  to 
pass  by  without  notice. 

In  discussing  the  treatment  of  this  grave  condition,  the  weight  of 
authority  obviously  leans  in  the  direction  of  resorting  to  surgical 
means  for  clearing  the  obstructed  ureter  after  such  measures  as  a 
reasonable  amount  of  fomenting,  massage,  and  shampooing  have 
failed.  The  internal  administration  of  cannabis  indica  has  proved 
of  service  where  there  is  evidence  of  ureteral  spasm,  but  pain  is  not 
always  a  feature  of  this  variety  of  obstruction. 

If  these  means  are  not  speedily  effectual  the  surgeon  will  do  well 
not  to  wait  for  the  improbable  to  happen,  but  to  proceed  at  once  to 
make  a  lumbar  exploration  of  the  kidney  involved.  As  a  rule  the 
latter  will  be  indicated  by  the  history  of  the  case  and,  as  in  an  in- 
stance presently  to  be  referred  to,  by  the  comparative  degree  of  ful- 
ness presented  by  the  loin.  Such  an  incision  will  permit  of  an  exam- 
ination not  only  of  the  pelvis  of  the  kidney  but  also  of  the  upper  part 
of  the  ureter,  localities  where  stones  have  been  frequently  found.  If, 
on  the  other  hand,  the  obstruction  is  in  the  inferior  or  vesical  portion 
of  the  ureter,  some  dilatation  may  be  discovered  on  incision  indicat- 
ing this,  when  the  pelvis  of  the  kidney  should  be  forthwith  opened 
and  the  canal  explored  by  means  of  a  ureteral  bougie.  Failing  to 
dislodge  the  obstruction  in  this  way  a  pelvic  or  ureteral  drain  in  the 
lumbar  region  would  at  all  events  be  established  as  a  temporary  ex- 


OBSTEUCTION  OF  THE  UKETEES.  189 

pedient.  A  channel  being  thus  provided  for  the  discharge  of  urine, 
a  further  search  may  be  made  for  the  obstniction  on  a  future  occa- 
sion on  the  lines  laid  down  in  my  previous  remarks  on  unilateral 
impacted  calculus.  In  the  mean  time  immediate  risk  to  life  would  be 
averted. 

In  Mr.  Lucas'  successful  case  of  nephrolithotomy  following  ne- 
phrectomy for  total  suppression  of  urine  lasting  five  days,  the  stone 
was  removed  from  the  pelvis  of  the  kidney.  It  is  described  "  "  as  of 
the  shape  to  act  as  a  ball  valve  to  the  top  of  the  ureter."  The  whole 
of  the  urine  was  passed  through  the  drainage  tube  and  lumbar  wound 
for  eleven  days  succeeding  the  operation,  when  healing  gradually 
took  place. 

Dr.  W.  Hind  "  records  a  case  of  total  suppression  of  urine  due 
to  an  impacted  calculus  with  atrophy  of  the  other  kidney  from  a  pre- 
vious similar  condition,  which  is  of  much  value.  It  occurred  in  a 
man  of  gouty  habits  who,  though  having  been  more  or  less  under 
observation  for  twenty  years  by  various  medical  men,  was  never  sus- 
pected of  suffering  from  any  kind  of  stone.  His  illness  was  ushered 
in  by  the  passage  of  a  renal  calculus  followed  by  complete  sujjpres- 
sion  of  urine,  which  continued  for  sis  days  without  the  development 
of  any  other  symptoms.  At  the  expiration  of  this  time  the  right  kid- 
ney was  exposed  by  the  usual  incision  from  the  loin,  this  side  being 
selected  solely  from  the  fact  that  there  was  a  sensation  of  greater 
volume  in  the  right  kidney  region  than  the  left.  The  kidney  was 
found  to  be  very  large  though  healthy.  At  the  top  of  the  ureter  a 
hard  lump  was  felt  and  removed,  which  proved  to  be  a  stone  weighing 
six  grains.  Higher  up  in  the  pelvis  of  the  kidney  other  stones  were 
felt  and  were  pressed  down  so  as  to  escape  by  the  incision  that  had 
already  been  made  in  the  ureter.  The  kidney  was  then  brought 
down  and  explored  by  an  incision  along  its  convex  border,  when  a 
triangular  stone  weighing  thirty-six  grains  was  removed.  No  sutures 
were  used  either  for  the  incisions  in  the  kidney  or  for  those  in  the 
ureter.  There  was  little  or  no  bleeding,  and  the  wound  was  brought 
together  for  the  greater  part  by  superficial  and  deep  sutures.  Twenty- 
four  hours  after  the  operation  there  was  not  an  unfavorable  symptom, 
and  urine  was  passed  abundantly  both  from  the  wound  and  by  the 
bladder.  Forty-eight  hours  after  the  operation  the  heart  begun  to  fail 
and  the  patient  sank,  in  spite  of  stimulants,  shortly  afterward.  At 
the  autopsy  the  left  kidney  was  represented  by  a  mere  shell  enclos- 
ing a  mass  of  calculous  deposit  weighing  360  grains.  In  commenting 
upon  the  case  Dr.  Hind  observes :  "  To  such  an  extent  were  we  in  the 
dark  as  to  which  side  to  attack  first,  that  the  question  of  a  preliminary 
abdominal  dissection  was  discussed,  but  negatived  on  account  of  the 


190  HAHEISON — DISEASES  OF  THE  KIDNEYS  AND  UEETERS. 

weak  state  of  tlie  patient's  general  liealth.  The  rapidity  witli  whicb. 
tlie  urinary  secretion  was  establislied  after  removal  of  the  plugging 
stone  was  remarkable," 

Another  instance  is  recorded  by  Dr.  Newman  '^^  where  death  fol- 
lowed suppression  of  urine  which  had  existed  for  five  days.  At  an 
autopsy  symmetrical  blocking  of  both  ureters  with  calculi  was  found. 
It  is  possible  that  in  view  of  a  contingency  of  this  kind  in  connection 
with  a  case  of  suppression  of  urine,  which  did  not  happen  to  pos- 
sess what  I  may  speak  of  as  a  previous  history,  the  selection  of  a 
laparotomy  might  seem  preferable.  There  is  this,  however,  to  be 
remembered :  that  even  if  such  a  rare  occurrence  were  seemingly  en- 
countered as  bilateral  and  synchronous  occlusion,  the  opening  of  one 
ureter  or  the  pelvis  of  a  kidney  would  at  least  tide  over  the  pressing 
emergency,  at  no  great  risk,  and  afford  time  for  any  further  action 
to  be  taken. 

Mr.  F.  W.  Kirkham"  records  a  case  where  a  man  aged  fifty-eight 
had  suffered  from  right  renal  colic  six  years  previously,  when  he 
passed  a  small  calculus.  This  was  followed  by  a  similar  attack 
about  a  year  afterward,  when  the  pain  suddenly  ceased.  On  the 
present  occasion  the  patient  was  taken  with  pain  running  downward 
from  the  left  loin  to  the  testicle.  The  pain  after  lasting  for  about  an 
hour  again  suddenly  disappeared,  and  he  thought  the  stone  had 
passed  into  the  bladder.  Suppression  of  urine,  however,  supervened 
and  continued  for  over  six  days.  Symptoms  of  headache  and  drowsi- 
ness with  great  prostration  and  muscular  twitching  setting  in,  an  ex- 
ploratory operation  by  a  lumbar  incision  was  resolved  upon.  After 
carefully  exploring  the  kidney  and  finding  no  stone,  the  exploration 
was  continued  downward  along  the  ureter,  when  a  calculus  was  felt 
half  an  inch  above  where  the  duct  crosses  the  commencement  of  the 
external  iliac  artery.  By  an  incision  the  calculus  was  extracted  and 
proved  to  be  the  size  of  a  date-stone.  Very  little  urine  escaped  from 
the  opening  and  the  hemorrhage  was  slight.  A  drainage-tube  was  in- 
troduced and  the  superficial  wound  brought  together  by  sutures. 
Half  an  hour  after  the  operation  an  ounce  and  a  half  of  urine  was 
passed  naturally.  The  wound  healed  kindly  and  recovery  was  com- 
plete. 

Dr.  Ealfe  and  Mr.  Godlee  relate  "  a  case  of  suppression  lasting 
fifty-three  hours  in  a  woman.  The  left  kidney  was  first  exposed  by 
lumbar  incision  and  a  small  calculus  was  removed  from  the  ureter  about 
two  inches  below  the  organ.  The  bladder  and  the  lower  ends  of  the 
ureters  had  been  previously  explored  by  dilating  the  urethra  with  the 
finger.  Large  quantities  of  urine  were  passed  by  the  wound,  but 
none  by  the  urethra  for  three  days.      Subsequently  symptoms  of 


OBSTEUCTION  OF  THE  URETEES.  191 

right  renal  colic  developed.  Twenty-six  days  after  tlie  first  operation 
the  other  kidney  was  explored  in  a  similar  way,  but  only  a  mass 
of  gravel  was  found  in  it.  On  the  day  following  a  small  stone  was 
passed  by  the  urethra.     The  patient  recovered. 

Dr.  El.  Morison  ^^  reports  a  case  of  suppression  of  urine  in  a  man 
forty-six  years  of  age.  The  diagnosis  arrived  at  was  "  that  the  right 
ureter  was  blocked  by  a  calculus,  and  that  the  left  kidney  was  for 
some  reason  or  other  Jio7^s  de  combat.''  The  urgent  symx)toms  having 
extended  over  fourteen  days,  during  which  period  suppression  was 
almost  complete,  on  the  development  of  signs  of  urasmic  poisoning 
the  right  kidney  was  exposed  by  the  oblique  incision  in  the  loin.  No 
stone  was  found  in  the  kidney,  but  the  pelvis  and  upper  end  of  the 
ureter  were  felt  to  be  considerably  dilated.  The  incision  was  then 
prolonged  to  the  centre  of  Poupart's  ligament  and  the  dilated  ureter 
was  exposed  in  the  pelvis.  One  stone  about  the  size  of  a  filbert  and 
another  smaller  one  were  discovered  firmly  impacted  in  a  position 
thought  to  be  close  to  the  bladder.  These  were  removed  through  an 
incision  made  in  the  ureter  which  was  sutured  with  fine  catgut.  The 
patient's  breathing  had  become  steadily  more  difficult  and  altogether 
ceased  just  before  the  completion  of  the  skin  suturing. 

Necropsy :  The  amount  of  fat  was  enormous.  It  was  evident  that 
the  right  kidney,  its  pelvis,  and  the  whole  length  of  the  ureter  had 
been  explored.  The  right  ureter  throughout  was  as  large  as  a  sau- 
sage. Within  an  inch  of  the  bladder  there  was  an  opening  in  it  one 
inch  long  secured  by  a  catgut  suture.  The  opening  into  the  bladder 
was  free.  There  were  no  stones  in  the  ureter,  pelvis,  or  kidney. 
The  kidney  was  sacculated  and  much  diseased,  being  in  a  condition 
of  advanced  interstitial  nephritis.  The  left  ureter  was  completely 
blocked  about  the  middle  by  a  stone.  Above  and  below  the  obstruc- 
tion the  ureter  was  dilated.  The  left  kidney  was  sacculated,  and  no 
trace  of  healthy  kidney  substance  was  left.  It  was  evident  that  this 
kidney  had  not  been  in  use  for  a  long  time. 

I  have  now,  in  the  first  place,  endeavored  to  illustrate  various 
methods  by  which  the  surgeon  may  succeed  in  relieving  the  obstruc- 
tion in  cases  of  unilateral  impaction  of  the  ureter  by  stone.  Such  a 
course  would  be  indicated  partly  by  the  persistence  of  pain  and  the 
urgency  of  symptoms  and  partly  by  the  consideration  that,  unless 
mechanical  relief  is  afforded  either  by  nature  or  art,  the  destruction 
of  the  kidney  necessarily  ensues.  With  this  knowledge  before  the 
I^ractitioner,  the  character  of  the  non-operative  measures  to  be  first 
employed  and  their  duration  must,  after  what  has  already  been  said 
and  illustrated,  be  left  in  a  large  measure  to  indivi(lu;d  discretion. 

In  reference  to  the  second  class  of  cases,  where  both  ureters  are 


192  HAKKISON — DISEASES   OE  THE  KIDNEYS  AND  UEETEES. 

obstructed  and  there  is  more  or  less  complete  suppression  of  urine 
arising  from  a  mechanical  obstruction,  tlie  surgeon  must  not  delay 
making  an  attempt  to  free  at  least  one  of  the  ureters  until  ursemic 
symptoms  are  developed.  In  the  absence  of  direct  evidence  indicat- 
ing the  precise  position  of  the  stone,  he  will  probably  do  well  in  tak- 
ing the  lumbar  incision  as  the  basis  of  his  operations  and  making  the 
needful  explorations  from  this  position  on  the  lines  that  have  been 
illustrated.  In  the  entire  absence  of  all  local  or  leading  indications 
an  exploratory  laparotomy  would  be  expedient. 

I  have  hitherto  illustrated  some  of  the  more  acute  forms  of  unilat- 
eral and  bilateral  ureteral  obstruction ;  there  are  others  to  which  I 
will  now  refer,  in  the  same  manner,  where  though  the  processes  are 
slower  the  effects  on  the  kidney  involved  are  equally,  though  more 
remotely,  disastrous.  Some  of  these  can  hardly  be  said  to  be,  at 
present,  within  reach  of  surgery.  This,  however,  by  no  means  im- 
plies that  they  are  beyond  the  limits  of  our  consideration  or  pros- 
pective resources.  Some  of  these  conditions  are  incidentally  referred 
to  in  a  general  way  in  connection  with  the  subjects  of  pyo-  and  hydro- 
nephrosis. 

Dr.  W.  H.  Dickinson  "  records  a  fatal  case  where  an  aneurism  of 
the  abdominal  aorta  which  eventually  burst  into  the  colon  was  ad- 
herent to  the  left  ureter.  It  caused  symptoms  attended  with  most 
severe  pain  which  it  is  stated  were  in  some  respects  not  unlike  those 
of  a  stone  moving  in  the  ureter.  The  tumor  that  was  thus  formed, 
and  described  as  being  the  size  of  an  orange,  rendered  the  diagnosis 
very  obscure. 

Mr.  Barker  ^°  has  brought  under  notice  an  instance  where  in  a  case 
of  extreme  prolapse  of  the  uterus,  vagina,  and  bladder  the  ureters 
and  renal  pelves  were  dilated.  The  obstruction  was  doubtless  caused 
by  the  alteration  in  the  direction  of  the  ureters  as  they  entered  the 
bladder,  as  well  as  by  their  jjressure  against  the  plibic  arch.  Benal 
tenderness  and  reflected  pain  therefrom  may  be  caused  and  maintained 
by  the  tension  exercised  by  the  ureter,  as  in  pelvic  growths  and  in 
displaced  organs.  In  females  particularly,  bladder  pains  may  be 
accounted  for  in  this  way  and  remedied  by  the  removal  of  the  cause, 
if  practical.  A  vesical  pain  does  not  necessarily  imply  a  vesical 
origin. 

Dr.  Sainsbury  "  has  illustrated  a  very  perfect  valve  in  the  ureter 
which  was  the  probable  cause  of  a  pyonephrosis.  It  occurred  in  a 
woman  thirty-four  years  of  age.  The  ureter  where  it  entered  the 
kidney  swelled  out  rather  suddenly,  and  on  opening  the  tube  two 
small  flap-like  valves  were  found,  on  the  same  level,  which  effectually 
prevented  all  escape  from  the  kidney. 


OBSTEUCTION  OP  THE  UEETEES.  193 

Mr.  Shield "  records  a  case  where  a  cancer  of  the  bladder  ob- 
structed both  ureters  and  produced  the  usual  effects.  I  have,  in  the 
section  on  surgical  diseases  of  the  kidneys,  referred  to  an  instance 
under  my  own  observ^ation  where  an  enormous  pelvic  hydatid  in  a 
man  acted  in  a  similar  way. 

Dr.  Tirard ""  describes  a  rare  case  of  tubercular  growth  in  the 
ureter  in  a  boy  five  years  of  age  with  a  tubercular  history  who  was 
under  treatment  for  general  dropsy.  The  urine  was  always  faintly 
acid,  free  from  albumin,  and  with  a  specific  gravity  from  1.010  to 
1.020.  The  left  ureter  was  found  constricted  by  a  hard  tubercular 
nodule  which  would  not  allow  a  fine  probe  to  pass  without  force. 
The  pelvis  of  the  kidney  was  much  dilated.  It  is  stated  that  no  tu- 
bercles were  to  be  seen  on  the  mucous  surface  of  the  bladder  or  in  the 
substance  of  the  kidney.  The  tubercular  deposit,  therefore,  seemed 
confined  to  the  ureter. 

Mr.  Targett  ^'describes  a  case  of  sarcoma  in  the  following  words: 
"  The  ureter  was  invaded  by  a  new  growth  from  without  which,  having 
reached  the  interior  of  the  duct,  filled  and  even  distended  its  channel 
and  then  spread  downward  to  the  bladder."  The  clinical  features 
were  those  of  an  abdominal  growth  of  some  months'  duration,  in  a 
man  aged  forty-six,  the  urine  containing  round  and  spindle  cells 
and  blood  clots.  The  patient  died  emaciated.  In  a  somewhat  simi- 
lar case  ""  the  ureter  was  filled  with  malignant  growth,  apparently  sar- 
coma, which  had  extended  upward  from  a  primary  source  in  the 
bladder. 

Dr.  S.  West ''"  records  a  case  where,  in  a  man  aged  seventy-four, 
who  died  from  gangrene  of  the  foot,  the  left  ureter  was  found  obliter- 
ated by  an  omentum  adherent  to  the  brim  of  the  pelvis.  There  was 
a  compensatory  hypertrophy  of  the  opposite  kidney. 

An  obstructive  condition  of  extremely  rare  occurrence  has  been 
described  and  illustrated  by  Mr.  Eve  and  Mr.  Bland  Sutton ''  under 
the  name  of  psorospermial  cysts.  It  has  also  been  referred  to  as 
mucous  cysts  of  the  ureters.  The  disease,  though  very  exceptional 
in  the  human  species,  is  extremely  common  in  rabbits,  and  appears  to 
be  limited  to  the  mucous  membrane.  Eve  refers  to  a  case  where  the 
disease  occurred  in  a  woman  aged  fifty-one.  She  was  taken  suddenly 
ill,  the  prominent  symptoms  being  hsematuria  with  exceedingly  fre- 
quent and  painful  micturition.  Death  took  place  from  exhaustion 
and  anaemia  seventeen  days  after  the  beginning  of  her  illness.  The 
kidneys  and  bladder  were  healthy.  Microscopic  sections  made  at 
right  angles  to  the  ureter  showed  cysts  of  various  sizes  filled  with 
colloid  material,  in  which  were  many  oVoid  bodies  corresponding  in 
appearance  and  size  to  pseudo-navicellse. 
Vol.  L— 13 


194  HAERISON — DISEASES  OE  THE  KIDNEYS  AND  UEETEES. 

Dr.  W.  B.  Hadden "'  demonstrated  tlie  obstruction  of  a  ureter  by 
a  gumma  in  a  man  aged  fifty -five,  wbo  died  of  strangulated  hernia. 
The  kidney  and  the  portion  of  the  ureter  above  the  constriction  were 
dilated.     There  were  other  syphilitic  gummata  in  the  liver  and  spleen. 

St.  George's  Hospital  Museum  contains  a  specimen  where  a  cal- 
culus was  found  almost  filling  one  of  the  ureters  and  measuring  five 
and  a  half  inches  in  length. 

It  is  under  such  varied  circumstances  as  are  here  illustrated  that 
the  surgeon  may  be  called  upon  to  devise  those  measures  for  mechani- 
cal relief  which  may  be  necessary  in  connection  with  an  obstructed 
ureter.  It  is  only  by  a  comprehensive  knowledge  of  the  different 
conditions  under  which  ureteral  obstruction  is  likely  to  occur  that  the 
practitioner  is  enabled  to  recognize  those  which  are  probabl}^  remedi- 
able by  the  application  of  his  art,  as  well  as  to  draw  his  conclusions 
as  to  the  time  and  nature  of  the  proceeding  to  be  adopted,  according 
as  signs  of  urgency  or  danger  are  developed. 

Congenital  and  Acquired  Malformations  of  the  Ureters. 

As  the  integrity  of  the  kidnej^s  is  to  a  large  extent  dependent  on 
the  condition  of  the  ducts  by  which  the  urine  is  conveyed  to  the 
bladder,  it  will  be  proper  to  consider  other  sources  of  interruption  in 
addition  to  the  stoppages  that  are  occasioned  in  these  tubes  by 
calculi  and  strictures  in  the  ordinary  acceptation  of  the  term.  Hav- 
ing referred  to  this  subject  already  in  connection  with  the  conditions 
just  named  as  well  as  with  hydronephrosis,  my  remarks  will  now  be 
confined  to  certain  congenital  and  acquired  malformations  of  the  ure- 
ters. It  is  necessary  that  the  surgeon  should  have  some  knowledge 
of  these  deviations,  otherwise  in  the  case  of  an  exploration  he  might 
find  himself  considerably  embarrassed. 

It  will  hardly  be  requisite  to  indicate  all  the  congenital  varieties 
that  have  been  met  with,  after  what  has  been  said  in  my  description 
of  the  malformations  of  the  kidney.  If  a  person  is  born  with  only 
one  kidney  it  stands  to  reason  that  this  will  probably  be  represented 
by  a  single  duct.  On  the  other  hand  instances  are  recorded  where 
one  kidney  has  had  two  or  even  more  ureters,  which,  as  a  rule,  have 
coalesced  into  one  tube  before  entering  the  bladder.  Sir  William 
Roberts  gives  an  instance  where  the  ureters  crossed  on  their  way  to 
the  bladder.  In  what  are  called  horseshoe  kidneys,  where  the  two 
organs  are  united  by  a  transverse  bar,  either  at  their  base  or  at  their 
apex,  there  are  usually  two  ureters,  which  descend  in  front  of  the  con- 
necting link.  According  to  Dr.  Wilks  there  are  exceptions  to  this, 
the  ducts  descending  occasionally  behind  the  bridge.     Sir  Henry 


CONGENITAL  AND  ACQUIRED   MALFOEMATIONS  OP  THE  UEETERS.     195 

Thompson"  saw  a  kidney  with,  two  ducts  which  united  into  a  single 
ureter  about  an  inch  below  their  necks.  Mr.  J.  Wood,"  on  the  other 
hand,  has  described  an  instance  where  the  union  did  not  take  place 
until  about  an  inch  from  the  bladder. 

Reference  has  already  been  made  to  the  great  dilatation  the  ure- 
ters sometimes  undergo.  These  tubes  have  been  found  to  resemble 
in  size  a  portion  of  the  small  intestine.  When  produced  by  distal 
causes,  as  for  instance  i)rostatic  obstruction  or  urethral  stricture,  by 
containing  urine  and  undergoing  inflammation  they  add  materially 
to  the  gravity  of  the  case.  Where  the  obstruction  in  front  of  the 
bladder  is  so  great  as  to  induce  this  and  to  threaten,  by  its  persis- 
tence and  resistance  to  all  ordinary  treatment,  extension  of  the  in- 
flammation to  the  kidneys  and  their  dilatation  and  eventual  disin- 
tegration, the  surgeon  is  justified  in  entertaining  measures  which 
will  permit  of  a  free  and  incontinent  escape  of  urine  from  the  bladder. 
The  adoption  of  some  form  of  bladder  drainage  under  these  circum- 
stances is  often  to  be  recommended.  The  technique  of  this  proceed- 
ing, which  is  one  that  does  not  entail  additional  risk  so  far  as  the 
operation  is  concerned,  is  fully  described  in  my  article  on  diseases  of 
the  bladder.  That  the  consequences  of  obstruction  in  front  are  extend- 
ing to  the  ureters  and  are  commencing  to  influence  the  kidneys  may 
be  inferred  by  various  circumstances  which  gradually  develop  in 
connection  with  some  of  the  worst  forms  of  prostatic  and  urethral 
obstruction.  More  especially  are  they  to  be  observed  in  association 
with  that  variety  of  dense  and  contractile  strictures  which  results  from 
wounds  and  laceration  of  the  male  urethra. 

The  mode  in  which  dilatation  of  one  or  both  ureters  is  usually 
brought  about  is  through  the  expulsive  pressure  of  a  normally  dis- 
posed or  an  hypertrophied  bladder  upon  its  contents,  much  in  the 
same  way  that  pressure  with  the  hand  on  a  rubber  ball  syringe,  un- 
protected by  valves,  has  a  tendency  to  drive  its  contents  into  both 
the  afferent  and  the  efferent  tubes  with  which  it  is  connected.  In 
this  way  in  a  case  of  urethral  stricture  dilatation  of  the  ureters 
as  well  as  of  the  urethra  on  the  proximal  side  of  the  obstruction  is 
gradually  brought  about. 

There  are,  however,  examples  where  the  process  is  somewhat 
different;  excluding  cases  where  the  ureters  are  dilated  by  what  de- 
scends, as,  for  instance,  the  frequent  passage  of  renal  calculi,  of  pus, 
and  of  other  fluid  and  semi-solid  contents  of  the  kidneys  in  the  course 
of  disease,  there  are  others  which  do  not  admit  of  explanation  in 
these  ways.  Specimens  are  occasionally  met  with  in  young  persons 
where  the  ureters  are  enormously  dilated  and  yet  no  mechanical  ex- 
planation of  this  can  be  found  in  the  bladder  or  its  contents,  or  in 


196  HAEEISON— DISEASES   OF  THE   KIDNEYS  AND  UEETJERS. 

any  portion  of  the  urethra,  prostatic  hypertrophy  being,  of  course, 
out  of  the  question.  In  a  case  reported  and  commented  on  by  Dr. 
Dawson  Williams  ^"^  in  a  boy  five  and  a  half  years  of  age,  no  other 
conclusion  could  be  arrived  at  than  that  the  dilatation  of  both 
ureters  and  kidneys  was  probably  of  congenital  origin,  an  assumption 
which  Mr.  Targett  has  also  offered  in  explanation  of  some  forms  of 
sacculation  of  the  bladder.  That  frequent  spasm  of  the  bladder  is 
sometimes  a  cause  of  dilatation  above  I  can  have  no  doubt.  I 
have  seen  this  on  several  occasions  in  both  sexes  in  cases  of  tubercu- 
lar ulceration  limited  to  the  bladder,  where  the  latter,  though  of  small 
capacity,  was  kept  in  an  almost  constant  state  of  contraction. 

As  I  have  urged  that  in  the  ordinary  forms  of  ascending  ureteral 
and  renal  dilatation  and  disintegration,  observed  in  connection  with 
serious  kinds  of  obstructive  disease  lower  down,  other  measures  fail- 
ing, free  and  incontinent  urine  drainage  should  be  established,  I  will 
proceed  to  notice  some  indications  relative  to  the  incidence  of  these 
serious  and  very  fatal  complications. 

In  the  first  place  it  must  be  remembered  that  they  are  the  out- 
come and  natural  termination  of  the  most  serious  forms  of  prostatic 
and  urethral  obstruction.  I  have  seen  many  cases  of  traumatic  stric- 
ture ending  in  this  way  and  in  death  from  uraemia  by  reason  of  the 
almost  entire  absorption  of  kidney  tissue.  Sufficient  stress,  how- 
ever, has  already  been  laid  upon  this  point. 

The  probability  that  these  ascending  changes  are  advancing  is 
frequently  indicated  by  certain  abdominal  expressions  which,  taken 
in  connection  with  the  nature  of  the  obstruction,  cannot  be  otherwise 
than  highly  suggestive.  Where  the  ureters  have  been  very  large  I 
have  distinctly  been  able  to  make  out  by  deep  pressure  with  the  hand 
bilateral  vertical  prominences  in  the  direction  of  the  kidneys  in  con- 
tradistinction to  the  feel  that  ordinary  intestine  affords  to  the  touch. 
Lines  of  perpendicular  sensitiveness  can  thus  often  be  made  out. 
Though  tenderness  over  the  kidneys  can  generally  be  discovered  if 
looked  for,  perceptible  fuhiess  or  swelling  is  •  rarely  made  out  until 
these  organs  have  become  seriously  involved.  Sensitiveness  on  pres- 
sure over  the  kidneys  in  both  prostatic  and  urethral  obstruction  is 
often  significant. 

In  this  aspect  of  obstructive  disorders  below  the  bladder  ther- 
mometric  observations  are  often  of  much  value.  A  dilated  ureter  is  a 
tube  that  is  rarely  empty.  Small  quantities  of  urine  collect  in  de- 
pendencies within  it,  and  local  inflammation  is  excited,  and  this  is 
often  indicated  by  irregular  temperatures.  I  have  made  many  obser- 
vations of  this  kind  in  connection  with  chronic  prostatic  and  stricture 
cases  where  the  ureters  and  kidneys  have  eventually  proved  to  be  both 


CONGENITAL  AND  ACQUIRED  MALFORMATIONS  OP  THE  URETERS.   197 

dilated  and  inflamed.  It  is  quite  a  different  temperature  chart  to 
that  which  is  seen  in  the  ordinary  forms  of  urethral  fever  following 
the  use  of  instruments.  In  the  former  case  the  variations  are  more 
like  those  which  occur  in  what  we  used  to  speak  of  as  hectic  fever. 
Then  again  there  is  often  thirst  and  a  dry  tongue,  and  the  patient  is 
generally  materially  relieved  by  flushing  the  kidneys  with  some  bland 
antiseptic  fluid.  There  is  difficulty  in  doing  this  when  the  obstacles 
in  the  way  of  expelling  urine  from  the  bladder  are  considerable.  On 
the  other  hand,  when  bladder  drainage  has  had  to  be  provided  to 
secure  incontinent  and  free  expulsion  of  the  urine  from  the  bladder, 
independently  of  the  will,  a  diuresis  of  this  kind  is  often  most 
beneficial. 

Then  in  the  last  place  the  urine  of  back-pressure  and  supra-vesi- 
cal  dilatation  may  be  suggestive.  It  is  often  purulent,  with  a  faintly 
acid  reaction  when  recently  passed,  and  with  a  low  specific  gravity. 
It  is  to  this  class  of  cases  irrespective  of  age  that  Sir  James  Paget' s" 
remark  is  appropriate :  "  Let  me  tell  you  of  a  symptom  which  must 
make  you  specially  cautious  if  you  have  to  catheterize  elderly  or  old 
men.  If  they  are  passing  large  quantities  of  pale  urine  of  a  very  low 
specific  gravity,  whether  containing  a  trace  of  albumin  or  not,  they 
will  be  in  danger  from  even  the  most  gentle  catheterism.  For  this 
condition  of  the  urine  is  often  due  to  some  advanced  defect  of  action 
in  the  kidneys,  and  a  catheterism  will  be  followed  by  inflammation  of 
the  bladder  and  the  so-called  urinary  fever,  and  death  will  hardly  be 
escaped." 

The  urine  that  is  secreted  under  a  high  pressure,  as  where  ob- 
struction, though  not  complete,  is  considerable,  is  described  by  Sir 
William  Roberts  as  "  very  pale,  watery,  devoid  of  its  proper  coloring 
matter,  poor  in  urea,  and  of  low  specific  gravity.  It  may  indeed  be 
tinged  with  blood,  but  this  is  an  accidental  circumstance."  I  have 
frequently  seen  urine  which  for  some  time  had  presented  these  char- 
acteristics in  some  advanced  forms  of  traumatic  urethral  stricture 
where  dilatation  of  the  ureters  and  kidneys  was  probably  going  on, 
immediately  assume  more  healthy  characteristics  after  all  tension 
has  been  taken  off  by  a  suitable  bladder  drainage  being  provided.  By 
these  means  the  excretion  may  be  observed  to  return  gradually  to  a 
normal  standard,  with  permanent  advantage  to  the  patient.  This  is 
an  exx^edient  which  must  not  be  lost  sight  of  in  connection  with  the 
mechanical  treatment  of  these  progressive  dilatations. 

Instances  are  recorded  where  dilated  ureters  appear  to  have  served 
the  x>urpose  of  subsidiary  bladders.  Here  it  is  probable  that  the 
obstructions  were  not  progressive,  and  though  urine  might  have  been 
retained  in  these  dilated  tubes  the  flow  through  them  was  sufficiently 


198  HAERISON— DISEASES  OP  THE  KIDNEYS  AND  UBETERS. 

free  to  prevent  any  decomposition  of  tlie  excretion  taking  place. 
Cases  of  this  kind  with  observations  have  been  published  by  HutineF^ 
and  others. 

Some  malformations  and  displacements  of  the  ureters  which  have 
required  surgical  interference  may  be  noticed  here.  Dr.  F.  H. 
Davenport "  records  a  case  of  incontinence  of  urine  due  to  malposi- 
tion of  a  ureter.  The  patient  was  a  female,  aged  twenty-nine,  the 
mother  of  three  children,  who  had  suffered  from  incontinence  of 
urine  all  her  life.  This  was  found  to  be  due  to  "  a  malformation  of 
the  ureter,  which,  instead  of  turning  into  the  bladder  at  its  normal 
place,  was  continued  along  the  septum  between  the  bladder  and 
■vagina  and  emptied  by  a  special  opening  near  the  meatus."  Dr. 
Baker"  appears  also  to  have  described  and  subsequently  operated 
upon  a  similar  case.  Dr.  Davenport  states  "the  indication  in  his 
case  was,  if  possible,  to  dissect  up  the  ureter  from  its  bed  in  the  ante- 
rior vaginal  wall  to  a  point  corresponding  to  where  it  could  normally 
enter  the  bladder,  make  an  opening  into  the  bladder,  turn  the  ureter 
in  and  fasten  it  there,  and  then  close  the  fistula."  This  appears  to 
have  been  satisfactorily  accomplished. 

Mr.  Davies-Collej^  "  furnishes  the  pai-ticulars  of  a  case  he  treated 
for  protrusion  of  the  orifice  of  a  ureter  through  the  meatus  urinarius 
in  a  female  child.  Examination  with  the  finger  and  a  probe  showed 
that  the  protrusion  came  from  the  left  side  of  the  bladder.  The  mass 
was  ligatured  in  two  halves  so  as  not  to  obstruct  the  ureter,  and  was 
then  cut  off.  For  a  few  days  the  patient  seemed  relieved,  but  gradu- 
ally sank.  The  protrusion  was  confined  to  the  mucous  membrane 
surrounding  the  opening  of  the  ureter  and  did  not  involve  any  other 
portion  of  the  tube.     Caille  "  reports  a  very  similar  case. 

Ureteral  Fistulse. 

These  have  been  referred  to  incidentally  in  connection  with 
wounds  of  the  ureters  and  the  surgery  of  the  kidney,  and  do  not  re- 
quire any  special  consideration.  It  may  be  of  interest  to  recall  that 
the  kidney  was  first,  it  is  believed,  successfully  removed  for  a  lesion 
of  this  nature  by  Simon  of  Heidelberg.  It  is  hoped  that  the  neces- 
sity for  such  a  proceeding  may  be  rendered  less  frequent  by  the  sub- 
stitution of  those  plastic  attempts  to  restore  the  continuity  of  the 
tubes  which  have  been  noticed  in  the  course  of  this  article. 

In  thus  presenting  the  surgery  of  the  ureters  in  a  somewhat  sys- 
tematic form,  I  have  endeavored  to  collect  facts  bearing  upon  the 
integral  parts  of  it,  rather  than  to  draw  conclusions  which  would 
hardly  be  warranted  in  a  subject  of  so  comparatively  recent  develop- 


BrBLIOGRAPHICAL  REFERENCES.  199 

ment — much  that  is  here  described  and  illustrated  must  necessarily 
be  submitted  to  the  test  of  a  more  extended  experience,  which  is  now 
gradually  but  surely  forthcoming. 


Bibliographical  References. 

1.  The  Clinical  Journal,  August  1,  1894. 

2.  Liverpool  Medico-Chirurgical  Journal,  January,  1884. 

3.  Medical  Times,  October  31,  1885. 

4.  Medico-Chirurgical  Transactions,  1893. 

5.  The  Medical  Record,  September  15,  1894. 

6.  American  Journal  of  the  Medical  Sciences,  June,  1894. 

7.  Surgical  Diseases  of  the  Kidney,  Cassell,  1885. 

•   8.  Berliner  klinische  Wochenschrift,  Nos.  47,  48,  1888. 
9.  British  Medical  Journal,  April  30,  1892. 

10.  Transactions  of  the  Pathological  Society  of  London,  vol.  xxiiL 

11.  Edinburgh  Medical  Journal,  November,  1878. 

12.  Philosophical  Transactions,  1747. 

13.  Lancet,  March  10,  1888. 

14.  British  Medical  Journal,  January  31,  1891. 

15.  Lancet,  December  7,  1889. 

16.  Lancet,  January  3,  1880. 

17.  British  Medical  Journal,  November  24,  1888. 

18.  Rainey  :  Precise  Directions  for  the  Making  of  Artificial  Calculi,  with 
some  Observations  on  Molecular  Coalescence,  Transactions  of  the  Microscopical 
Society  of  London,  vol.  vi. ,  1858.  Ord :  On  Molecular  Coalescence,  and  on  the 
Influence  Exercised  by  Colloids  upon  the  Forms  of  Inorganic  Matter,  Quarterly 
Journal  of  Microscopical  Science,  vol.  xii. ,  New  Series,  1872.  Vandyke  Carter : 
The  Microscopic  Structure  and  Formation  of  Urinary  Calculi,  1878. 

19.  On  the  Cause  and  Distribution  of  Calculus.  Illustrated  with  colored  Maps 
showing  the  Distribution  and  Rainfall  in  England  and  Wales.  Nos.  1  and  2, 
1885-86. 

20.  On  Urinary  Diseases,  by  Sir  "William  Roberts.     Fourth  edition. 

21.  The  Etiology  and  Distribution  of  Stone  in  the  Bladder,  1874. 

22.  Glasgow  Medical  Journal,  May,  1887. 

23.  Transactions  of  the  International  Medical  Congress  for  1881. 

24.  Harveian  Lectures,  1889. 

25.  New  York  Medical  Journal,  January  10,  1885. 

26.  Lancet,  May  1,  1891. 

27.  Guy's  Hospital  Reports,  1860. 

28.  Persistance  du  Canal  de  Muller,  Publications  du  ProgrSs  Medical,  Paris, 
1887. 

29.  Intercolonial  Medical  Congress  of  Australia,  1889. 

30.  American  Journal  of  the  Medical  Sciences,  October,  1882. 

31.  Intercolonial  Quarterly  Journal,  August,  1894. 

32.  Archiv  fiir  Gynilkologie,  1870. 
38.  British  Medical  Journal,  1891. 

34.  British  Medical  Journal,  January  12,  1884. 

35.  Transactions  of  the  American  Surgical  Association,  1891. 

36.  Surgery  of  the  Kidney,  1886. 


200  HAEBISON — DISEASES   OP  THE  KIDNEYS  AND  UEETEES. 

37.  British  Medical  Journal,  1869. 

38.  Liverpool  Medico-Chirurgical  Journal,  January,  1894. 

39.  Tumors,  Innocent  and  Malignant,  1893. 

.  40.  Medico-Chirurgical  Transactions,  vol.  xxvii. 

41.  Guy's  Hospital  Reports,  1869. 

42.  Annals  of  Surgery,  May,  1894. 

43.  Journal  of  the  American  Medical  Association,  June  8,  1893. 

44.  Archiv  fur  klinische  Chirurgie,  Bd.  44,  Heft  4. 

45.  Annals  of  Surgery,  August,  1894. 

46.  Archives  Generales  de  Medecine,  January,  1894. 

47.  Lancet,  vol.  ii.,  1863. 

48.  British  Medical  Journal,  May  7,  1892. 

49.  Transactions  of  the  Pathological  Society  of  London,  vol.  xiii. 

50.  Lancet,  March  10,  1888. 

51.  Proceedings  of  the  Medico-Chirurgical  Society,  March  22,  1887. 
53.  Lancet,  Nov.  19,  1887. 

53.  Transactions  of  the  Medico-Chirurgical  Society,  May  8,  1894. 

54.  Transactions  of  the  Clinical  Society  of  London,  Jan.  24,  1890. 

55.  Lancet,  Nov.  8,  1890. 

56.  Lancet,  Nov.  10,  1894. 

57.  Boston  Medical  and  Surgical  Journal,  vol.  cxxiii. 

58.  American  Journal  of  the  Medical  Sciences,  October,  1884. 

59.  Transactions  of  the  Clinical  Society  of  London,  vol.  ii. 

60.  Medico-Chirurgical  Transactions,  vol.  Ixxiv. 

61.  British  Medical  Journal,  May  5,  1894. 

62.  British  Medical  Journal,  Jan.  15,  1876. 

63.  Lancet,  March  16,  1889. 

64.  Transactions  of  the  Clinical  Society  of  London,  Feb.  22,  1889, 

65.  Transactions  of  the  Pathological  Society  of  London,  vol.  xxvi. 

66.  Ibid. ,  vol.  xxxiv. 

67.  Ibid.,  vol.  xxxvii. 

68.  Ibid.,  vol.  xliii. 

69.  Ibid.,  vol.  xviii. 

70.  Ibid.,  vol.  xxxiii. 

71.  British  Medical  Journal,  1889,  vol.  ii. 

72.  Transactions  of  the  Pathological  Society  of  London,  vol.  vi. 

73.  Ibid.,  vol.  vii. 

74.  Paget,  Sir  James  :  Clinical  Lectures  and  Essays. 

75.  Bulletin  de  la  Societe  Anatomique  de  Paris,  1873. 

76.  Transactions  of  the  American  Gynecological  Society,  1890. 

77.  New  York  Medical  Journal,  Dec,  1878. 

78.  Transactions  of  the  Pathological  Society  of  London,  vol.  xxx. 

79.  American  Journal  of  the  Medical  Sciences,  1888. 


DISEASES  OF  THE  BLADDER. 


BY 


EEGINALD  HAERISON, 


LONDON. 


DISEASES  OF  THE  BLADDEE. 


RUPTURE  AND   INJURIES  OF  THE   BLADDER. 

EuPTUEE  or  bursting  of  tlie  bladder  may  be  caused  by  violence  ap- 
plied directly  over  it  wlien  it  is  in  a  more  or  less  distended  condition; 
by  penetration  from  within,  as  by  the  sharp  ends  of  fractured  bones, 
or  from  without,  by  bullets  and  other  missiles.  It  has  been  known 
to  give  way  under  artificial  distention  for  surgical  purposes,  and  it  is 
also  believed  to  have  been  ruptured  by  muscular  contraction. '  It  has 
been  occasionally  opened  accidentally  in  the  course  of  surgical  opera- 
tions involving  parts  in  its  immediate  contiguity. 

There  are  certain  general  considerations  to  which  reference  may 
first  be  made  before  proceeding  to  notice  the  varieties  the  injury  pre- 
sents in  view  of  their  treatment.  In  many  cases  of  rupture  of  the 
bladder  there  can  be  no  doubt  that  a  weakened  state  of  its  walls,  due 
to  long  standing  disease,  has  contributed  in  no  small  measure  to  this 
result.  This  circumstance  is  important  to  remember  where  we  have 
to  employ  distention  of  the  bladder  for  surgical  purposes,  as,  for  in- 
stance, in  supra-pubic  cystotomy,  where  the  resistance  of  the  coats 
of  the  viscus  is  occasionally  submitted  to  a  somewhat  severe  test.  In 
relation  to  contributing  causes  of  rupture  of  the  bladder,  Mr.  W.  H. 
Bennett  ^  has  reported  a  case  where  the  puncture  made  by  an  aspirator 
needle  preceded  this  event.  In  the  nest  place  stress  may  be  laid  upon 
the  importance  of  making  an  early  diagnosis  in  all  instances  of  this 
kind,  for,  if  the  rupture  is  to  be  closed  with  any  chance  of  success,  no 
time  should  be  lost.  Hence,  it  is  a  good  rule  in  cases  of  pelvic  in- 
jury, or  even  of  suspicion  that  such  may  have  occurred,  to  make  care- 
ful investigations  as  to  the  state  of  the  bladder,  and  if  necessary  to 
take  the  precaution  of  using  the  catheter.  If  a  direction  of  this  kind 
can  be  regarded  as  applying  to  conscious  patients,  it  does  so  with 
still  greater  force  to  those  who,  for  some  reason  or  other,  are  not  in 
possession  of  their  faculties.  In  more  than  one  instance  that  has  come 
to  my  knowledge  it  was  discovered  after  death  that  the  insensibility 
of  alcohol  or  i:)oison  led  to  a  lesion  of  this  kind  having  been  over- 
looked.    Though  in  none  of  the  cases  I  can  now  recall  was  the  rup- 


204  HAEKISON — DISEASES  OP  THE  BLADDER. 

tared  bladder  the  immediate  cause  of  death,  tlie  fact  that  it  compli- 
cated other  still  more  serious  conditions  must  not  be  forgotten. 
Further,  as  cases  of  this  kind  not  unfrequently  occur  in  connection 
with  matters  requiring  medico-legal  investigation,  such  as  in  fighting, 
sparring,  wrestling,  and  in  modern  football,  difficulties  sometimes 
arise  in  getting  at  the  facts,  for  which  allowance  should  be  made.  In 
hospital  practice  it  has  happened  that  this  lesion  has  not  been  recog- 
nized, because  not  suspected,  and  thus  complaints  have  arisen  in  con- 
sequence of  patients  having  been  allowed  to  go  to  their  homes  and 
to  remain  there  until  symptoms  developed.  Subsequent  autopsy, 
in  some  of  the  cases,  has  shown  the  difficulties  connected  with 
diagnosis  to  have  been  well-nigh  insuperable. 

Ruptures  of  the  bladder  are  of  two  kinds — intra-peritoneal  and  ex- 
tra-peritoneal. In  the  former  the  area  of  the  abdomen,  as  defined  by 
the  peritoneum,  is  opened  into,  and  urine  usually  enters  it;  while 
in  the  latter,  if  urine  escapes,  it  is  in  the  form  of  an  infiltration  around 
the  parts  constituting  what  is  called  the  neck  of  the  bladder,  where 
it  produces  effects  such  as  are  observed  in  more  superficial  parts  in 
connection  with  extravasation  of  urine. 

In  the  case  of  an  injury  applied  over  the  region  of  the  bladder, 
how  are  we  to  ascertain  that  this  organ  is  ruptured,  and  if  so, 
whether  the  rupture  involves  the  cavity  of  the  abdomen?  Having  de- 
termined these  iwo  points,  what  are  the  lines  of  treatment?  These 
three  aspects  will  now  be  considered.  In  addition  to  the  history  of 
the  injury  and  its  locality,  such  a  lesion  is  usually  attended  with  con- 
siderable shock.  If  the  urine  has  suddenly  escaped  into  the  perito- 
neal space,  this  collapse  may  be  spoken  of  as  profound,  and  perito- 
nitis generally  follows  with  much  acuteness.  Then  we  have  the  fact 
that  the  catheter  usually  draws  off  only  a  small  quantity  of  blood- 
stained urine,  and  possibly  it  may  at  the  same  time  be  noted  that  the 
instrument  passes  quite  easily  up  to  the  hilt,  giving  the  impression 
that  it  must  have  entered  the  abdominal  cavity,  which  is  often  the 
case.  Upon  the  latter  point  there  is,  however,  some  variation. 
Though  there  may  be  a  rent  directly  communicating  with  the  perito- 
neal cavity,  the  end  of  the  catheter  may  not  happen  to  pass  through 
it,  and  then  a  sensation  of  contraction  is  experienced  such  as  almost 
to  lead  the  surgeon  to  believe  that  the  instrument  has  not  taken  the 
natural  course.  Examination,  however,  by  the  finger  in  the  rectum 
generally  serves  to  indicate  that  the  instrument  is  in  its  right  posi- 
tion, but  is  firmly  grasped  by  the  contracted  viscus. 

Case. — In  a  case  of  extra-peritoneal  rupture  of  the  bladder,  which 
was  inflicted  by  a  man  falling,  while  wrestling,  and  striking  his  pros- 
trate opponent  with  his  knee  just  above  the  pubes,  there  was  the  sen- 


EUPTUEE  AND  INJURIES   OF  THE  BLADDER.  205 

sation  of  contraction  experienceed  in  introducing  a  metal  catheter, 
but  this  was  due  to  the  catheter  having  made  its  way  through  the 
rent  in  the  anterior  wall  of  the  bladder  immediately  above  the  pros- 
tate, which  was  also  involved  in  the  injury.  A  post-mortem  examina- 
tion showed  that  the  instrument  had  passed  through  the  rupture  and 
had  entered  the  porta  vesicce  of  Retzius.  Death  was  caused  by  cellu- 
litis, due  to  deep  urinary  extravasation.  Had  a  drainage-tube  been 
carried  through  the  rent  from  a  suprapubic  incision  into  the  porta 
vesica}  and  out  by  a  perineal  opening,  I  believe  the  man's  life  might 
have  been  saved,  as  the  case  really  resolved  itself  into  one  of  urine 
drainage. 

If  the  catheter  does  not  indicate  with  clearness  that  the  cavity  of 
the  peritoneum  is  opened,  the  distention  test  should  be  tried,  as  de- 
scribed by  Dr.  R.  F.  Weir,'  who,  after  stating  the  injuries  and  the 
symptoms  of  a  case,  remarks :  "  Only  two  procedures  seemed  avail- 
able, therefore,  viz. ,  digital  exploration  by  a  perineal  incision,  or  by 
opening  into  the  abdominal  cavity.  Rather  than  resort  to  either  of 
these  I  thought  of  using  the  test  of  distention  of  the  bladder-  as  em- 
ployed in  the  supra-pubic  opening  for  calculus,  tumors,  etc.  Ac- 
cordingly, two  hours  later,  the  abdominal  tenderness  having  in- 
creased, the  patient  was  etherized,  and  a  rubber  catheter  first  inserted 
into  the  bladder,  and  then  Peterson's  rubber  bag  passed  into  the  rec- 
tum and  distended  with  seven  and  a  half  ounces  of  warm  water.  After 
this  had  been  done,  and  the  line  of  supra-pubic  flatness,  now  slightly 
augmented,  outlined  by  a  colored  pencil,  seven  and  a  haK  ounces  of 
carbolic  acid  solution — 1  to  100  —were  slowly  introduced  into  the 
bladder.  When  six  ounces  had  been  passed  in,  the  contour  of  the 
bladder  could  be  felt  above  the  line  of  blood  extravasation,  and  the 
additional  quantity  of  fluid  served  only  to  make  this  more  posi- 
tive, especially  so  on  the  lateral  aspect  of  the  distended  viscus.  The 
injected  fluid  was  then  allowed  to  flow  from  the  bladder  and  meas- 
ured, and  found  to  correspond  with  the  quantity  forced  in.  The  de- 
monstration was  perfect,  not  only  as  to  the  impossibility  of  an  intra- 
peritoneal, but  also,  from  the  non-increase  in  the  line  of  dulness  over 
the  pubes,  as  to  an  extra-peritoneal  laceration.  The  rectal  bag  was 
thereupon  emptied  and  withdrawn,  and  the  patient  saved  from  any 
surgical  interference  of  a  more  heroic  character." 

The  diagnosis  of  intra-peritoneal  rupture  having  been  made,  lap- 
arotomy should  be  undertaken.  In  connection  with  this  proceeding 
we  are  indebted  to  Sir  William  MacCormac  for  the  first  successful 
records  of  closure  of  the  ruptured  bladder  by  suture.  Without  going 
into  the  details  of  the  two  cases  he  has  published,  stress  may  be  laid 
on  some  points  which  are  of  importance.  It  does  not  appear  to  have 
been  necessary  to  pare  the  edges  of  the  wound  in  the  bladder,  though 


206 


HAEEISON — DISEASES   OF  THE  BLADDER. 


great  pains  were  taken,  by  careful  approximation  of  tlie  sutures,  to 
make  tlie  bladder  water-tight,  and  thus  to  prevent  leakage.  Car- 
bolized  silk  sutures  were  used,  and  they  were  introduced  as  shown 
in  Fig.  33.    In  reference  to  the  use  of  a  catheter,  as  well  as  of  drainage 

of  the  abdomen.  Sir  Wil- 
liam remarks : '  "If  the 
rent  be  sutured  effective- 
ly, the  patient  runs  less 
risk  from  moderate  dis- 
tention of  the  bladder, 
which  is  all  that  can  pos- 
sibly occur  in  a  case  prop- 
erly watched,  than  he 
does  from  the  conse- 
quences of  retaining  a  ca- 
theter for  some  days 
within  the  viscus.  The 
experience  of  my  two 
cases  goes  far  to  prove 
that  the  catheter  may  in 
many  instances  be  safely 
dispensed  with  altogeth- 
er. I  am  sure,  too,  an  ab- 
dominal drainage-tube  is 
not  in  most  cases  need- 
ful, and  that  its  presence 
proves  a  source  of  danger 
to  the  patient." 

Though  there  can  be 
no  doubt  that  laparotomy 
and  suture  of  the  ruptured 
bladder  is  the  safest  course  to  be  pursued  in  cases  of  this  nature,  the 
question  may  be  raised  as  to  whether,  under  any  other  circumstances, 
repair  has  been  known  to  take  place.  In  reference  to  this  point,  the 
following  case,  recorded  by  Mr.  Henry  Morris, '  is  of  interest : 

Case. — The  patient  was  received  at  the  Middlesex  Hospital  in 
1879,  and  treated  for  a  rupture  of  the  bladder  consequent  upon  vio- 
lence. The  treatment  consisted  of  fomentations,  opium,  and  the  re- 
tention, just  within  the  neck  of  the  bladder,  of  a  gum-elastic  catheter. 
He  recovered  perfectly.  In  1886  he  was  again  admitted  into  the  Mid- 
dlesex Hospital,  and  died  shortly  afterward  of  rupture  of  the  blad- 
der. The  parts  removed  were  submitted  to  a  committee  who  reported 
"  the  specimen  exhibits  all  the  features  which  might  be  expected  at  a 
remote  period  after  rupture  of  the  bladder."     Mr.  Morris  remarks: 


Fig.  33.— Rupture  of  Bladder;  Showing  the  Arrangement 
of  Sutures.  The  upper  figure  is  the  same  in  cross-sec- 
tion.   Schematic. 


RUPTURE  AND  INJURIES  OP  THE  BLADDER.  207 

"  This  case  was  reported  in  1879  as  one  of  recovery  from  rupture  of 
the  bladder.  It  is  now  brought  before  the  Society  because  in  its  com- 
pleted form  it  affords  conclusive  proof  that  an  intra-peritoneal  rupture 
of  the  bladder  is  not  necessarily  fatal,  but  may  be  recovered  from 
under  the  simple  treatment  employed  in  this  case,  provided  the  urine 
at  the  time  of  the  rupture  is  of  normal  composition." 

Such  an  inference  as  Mr.  Morris's  case  suggests  is  warrantable 
from  other  circumstances  observed  in  connection  with  certain  appear- 
ances presented  after  death  in  some  instances  of  intra-peritoneal  rup- 
ture of  the  bladder,  in  conjunction  with  clinical  experience  relative 
to  the  drainage  of  urine  from  within  the  area  of  the  pelvis.  The  con- 
traction of  the  bladder  after  it  has  been  ruptured  and  its  contents  ex- 
pelled into  the  peritoneal  cavity,  as  noted  particularly  by  Mr.  Eiving- 
ton  in  his  excellent  treatise  on  this  subject,  is  so  great  as  to  render 
it  highly  probable  that  if  a  free  and  involuntary  exit  for  the  urine 
were  provided  within  a  reasonable  period  after  the  receipt  of  this  in- 
jury, nature  would  be  able  to  effect  the  rest  and  bring  about  recovery 
without  the  adoption  of  other  means.  So  far  as  my  experience  goes 
in  connection  with  the  various  ways  of  opening  the  bladder,  in  all 
of  which  I  may  say  I  have  had  some  experience,  the  only  one  that 
can  be  trusted  for  such  a  purpose  is  the  incision  made  for  lateral 
lithotomy,  as  combining  in  the  one  method  free,  involuntary,  and 
dependent  escape  of  the  urine  as  it  emerges  from  the  ureters.  On 
several  occasions  I  have  had  to  put  my  finger  into  the  bladder, 
through  the  wound,  within  a  few  days  after  a  lateral  lithotomy  has 
been  performed,  and  I  have  been  struck  with  the  firm  contraction 
of  the  viscus  with  which  this  procedure  was  invariably  met.  The 
following  case°  seems  to  support  this,  and  shows,  where  circumstances 
were  propitious,  how  nearly  the  imperfect  drainage  afforded  by 
catheterism  was  successful: 

Case. — At  the  time  of  the  accident,  which  was  caused  by  the  pa- 
tient's adversary  falling  upon  him  during  a  pugilistic  encounter,  a  sen- 
sation of  something  having  given  way  was  experienced.  He  walked 
home,  a  distance  of  two  miles,  when  he  was  seen  by  his  medical  atten- 
dant, who  drew  off  twenty  ounces  of  bloody  urine,  and  continued  to 
do  so  twice  a  day  for  three  days,  until  he  was  admitted  into  the  Lei- 
cester Infirmary  under  the  care  of  Mr.  Crossley.  On  his  admission, 
November  20th,  1872,  he  presented  the  following  signs :  He  was  able 
to  walk  without  assistance;  countenance  rather  anxious;  pulse  80, 
full ;  skin  cold ;  comx)lained  of  a  sensation  of  weight  in  the  hypogas- 
tric region,  but  no  tenderness  on  pressure.  On  percussion  over  the 
abdomen  an  increased  area  of  dulness  was  detected,  and  on  palpation 
a  distinct  sensation  of  fluctuation.  A  silver  catheter  was  introduced, 
and  thirty  ounces  of  clear  urine  drawn  off,  the  abdominal  dulness  and 
fluctuation  entirely  disappearing.     A  gum-elastic  catheter  was  subse- 


208  HARBISON — DISEASES   OF  THE  BLADDER.  .         ^ 

quently  passed  nigiit  and  morning.  The  patient  continued  in  mucli 
the  same  state  up  to  the  evening  of  December  1st,  when,  without  any 
premonitory  symptoms,  he  was  seized  with  a  severe  attack  of  convul- 
sions, rapidly  followed  by  coma.  Every  effort  was  made  to  rouse 
him ;  a  catheter  was  immediately  introduced,  and  about  twenty  ounces 
of  urine  drawn  off,  consciousness  returning  in  about  an  hour.  On 
the  following  day  he  was  again  attacked  in  a  similar  way,  and  on 
December  3d  he  was  seized  with  a  more  violent  form  of  convulsions, 
and  sank  in  three  hours  in  a  comatose  state. 

Post-3Iortem  Exainination. — On  opening  the  peritoneal  cavity, 
about  four  pints  of  clear  fluid  welled  up  through  the  incision.  The 
bladder  was  found  contracted  and  a  laceration  of  its  posterior  surface 
to  the  length  of  two  inches  was  detected  extending  in  an  oblique  di- 
rection.    In  other  respects  the  organs  i)resented  no  morbid  changes. 

This  case  presents  the  following  points  of  interest:  First,  the 
power  of  locomotion  after  so  serious  an  accident,  the  patient  hav- 
ing walked  to  his  home,  a  distance  of  two  miles,  immediately  after 
the  occurrence.  Secondly,  the  length  of  time  he  survived — sixteen 
clear  days — the  average  duration  of  life  in  these  cases  being  from 
three  to  seven  days.  Thirdly,  the  absence  of  all  signs  of  peritonitis. 
Fourthly,  could  the  death  of  the  patient  be  attributed  to  peritoneal 
absorption? 

In  view  of  what  has  been  effected  by  laparotomy  and  suture  in 
cases  of  intra-peritoneal  rupture  of  the  bladder,  no  other  treatment 
can  be  recommended,  unless  for  some  reason  or  other  it  is  found  im- 
possible to  give  effect  to  it. 

The  diagnosis  of  extra-peritoneal  rupture  of  the  bladder  is  some- 
what facilitated  by  excluding,  in  the  way  referred  to,  the  likelihood 
of  the  other  variety.  If  the  use  of  the  catheter,  in  conjunction  with 
the  history  of  the  case,  and  examination  by  the  rectum  are  insufficient 
to  indicate  this,  in  the  presence  of  a  lesion  evidently  involving  the 
mechanism  of  micturition,  a  perineal  puncture  into  the  membranous 
urethra  for  the  digital  exploration  of  the  neck  of  the  bladder  should 
be  proceeded  with.  Many  patients  in  cases  of  this  kind  have  un- 
doubtedly been  lost  for  the  want  of  that  knowledge  which  can  only 
be  thus  obtained.  Where  the  suspicion  is  grave,  the  possibility  of 
not  finding  such  a  lesion  by  exploring  should  not  be  allowed  to  weigh 
against  making  the  attempt.  If  a  pelvic  fracture,  with  rupture  of  the 
viscus,  or  rupture  alone,  is  discovered,  a  drainage-tube  should  be  in- 
serted in  the  bladder.  If  the  prevesical  space  is  also  opened,  an  ad- 
ditional aperture  above  the  pubes  will  be  required,  in  order  that 
through  drainage  may  be  provided.  Procedures  of  this  kind  are  safe 
and  slight  compared  with  the  risk  connected  with  extravasation  of 
urine  imperceptibly  going  on  in  a  part  where  otherwise  drainage  is 
impossible  and  subsequent  absorption  certain.     This  point  is  illus- 


EUPTURE  AND   mJURIES   OF  THE   BLADDER.  209 

trated  in  the  following  case  which  I  saw,  with  Dr.  C.  G.  Walker, 
at  the  Bootle  Hospital  in  1882 : 

Case. — The  patient,  aged  40,  a  fireman  on  board  a  steamer,  was 
brought  into  hospital  with  the  history  that  on  the  x)receding  day  the 
surgeon  of  the  ship  was  summoned  to  him  in  consequence  of  his  ina- 
bility to  pass  urine  and  of  pain  above  the  pubes.  It  was  thought  that 
he  had  been  drinking,  and  might  have  hurt  himself  when  stoking  coals. 
The  catheter  was  passed,  and  about  two  pints  of  blood-stained  urine 
drawn  off.  On  admission  the  abdomen  was  distended,  with  an  area 
of  dulness  on  percussion  and  tenderness  above  the  pubes ;  the  per- 
inseum  was  ecchymosed,  and  he  was  collapsed.  After  the  diagnosis  of 
rupture  of  the  bladder  had  been  made,  the  treatment  consisted  in  the 
retention  of  a  rubber  catheter  and  irrigation  of  the  bladder  with  a  weak 
carbolic  lotion.  An  erythematous  rash,  suggestive  of  extravasation, 
began  to  appear  over  the  right  iliac  region,  extending  haK-way  down 
the  thigh.  Vomiting  and  prostration  set  in,  and  the  patient  died  on 
the  fourth  day  after  the  presumed  injury.  At  the  autopsy  a  cavity 
about  the  size  of  an  orange,  filled  with  blood-clots,  was  found  behind 
the  pubes.  There  was  a  rupture  two  inches  in  length  in  the  anterior 
wall  of  the  bladder  where  it  is  uncovered  by  peritonaeum,  the  urethra 
being  normal.  Though  there  was  no  history  of  injury,  there  could 
be  no  doubt  that  the  lesion  was  due  to  a  blow  above  the  pubes  over 
a  full  bladder. 

The  following  case,  recorded  by  Dr.  Weir, '  illustrates  the  practice 
that  is  to  be  recommended  in  cases  of  this  description : 

Case. — "It  was  one  of  injury  to  the  pelvis  and  left  hip  of  a  man, 
aged  28,  by  a  fall  of  earth.  A  catheter  was  passed  on  his  admission 
to  the  New  York  Hospital  on  November  20th,  1883,  a  short  time  after 
the  accident,  which  gave  exit  to  a  moderate  amount  of  bloody  urine. 
The  injury  was  regarded  as  a  slight  urethral  laceration,  but  the 
marked  increase  in  the  supra-pubic  dulness,  which  now  extended  four 
inches  above  the  pubes  and  across  into  each  groin,  with  tenderness, 
led  to  a  closer  examination  of  the  patient.  The  catheter  passed  read- 
ily into  the  bladder  and  only  occasionally  gave  exit  to  blood-stained 
urine.  The  urine  itself  was  i^assed  at  times  voluntarily,  and  was  not 
apparently  diminished  in  amount.  The  temperature  was  but  99°. 
Abdomen  not  distended,  though  its  walls  above  the  dulness  were 
somewhat  rigid.  Condition  still  good.  No  signs  of  fracture  elicited, 
but  the  finger  in  the  rectum  detected  a  softer  spot  on  the  left  side  of 
the  prostate,  which  was  decidedly  painful.  The  ecchymosis  of  the 
scrotum  and  perineum  was  now  very  pronounced. 

"  November  24th.  The  temperature  had  risen  to  above  100°,  pulse 
104,  and  patient  began  to  be  restless  and  disposed  to  vomit.  Tym- 
panites increasing,  with  abdominal  tenderness  not  only  above  the  line 
of  dulness  but  below  it.  A  large  hypodermic  needle  inserted  in  the 
hyi)ogastrium  drew  out  some  bloody  fluid  with  an  acid  reaction  and 
urinous  odor.  Nothing  distinctive  could  be  felt  in  the  rectum.  The 
patient  was  etherized  and  an  incision,  under  sublimate  irrigation 
(1  to  1,000),  was  made,  three  and  one-half  inches  long  in  the  median 
Vol.  I.  — 14 


210  HAKEISON — DISEASES  OF  THE  BLADDEE. 

line,  midway  between  tlie  symphysis  and  umbilicus,  until  the  subperi- 
toneal cellular  plane  was  reached,  where  a  large  cavity,  containing  at 
least  a  pint  of  bloody,  undecomposed  urine,  was  found.  The  finger 
could  be  carried  its  full  length  behind  the  symphysis,  but  nothing 
could  be  detected.  To  effect  a  more  complete  diagnosis,  as  well  as 
to  allow  of  the  carrying,  if  possible,  of  a  drainage-tube  from  the 
hypogastric  opening  down  and  out  of  the  perineum,  the  patient  was 
placed  in  the  lithotomy  position,  and  on  a  staff  introduced  into  the 
bladder  a  median  incision  was  made,  opening  the  urethra  just  ante- 
rior to  the  prostate.  The  finger  passed  in  here  toward  the  bladder  re- 
vealed a  rent  running  along  the  left  side  of  the  roof  of  the  prostate 
which  was  lost  in  the  wall  of  the  bladder  itself.  Through  the  supra- 
pubic incision  a  large  silver  catheter  was  carried,  and,  aided  by  the 
finger  in  the  perineal  wound,  was  caused  to  pass  through  the  lacer- 
ation of  the  bladder  and  to  emerge  from  the  lower  wound.  To  the  eye 
of  this  catheter  a  thread  was  attached,  and  a  large  rubber  drainage- 
tube  pulled  through  as  the  silver  instrument  was  withdrawn.  Each 
end  of  the  tube  was  secured  by  a  suture  to  the  skin,  and  a  second 
drainage-tube  was  then  passed  into  the  bladder,  and  its  external  end 
also  fastened  in  the  perineum.  The  cavity  of  the  extravasation  and 
the  bladder  were  carefully  washed  out  with  a  warm  sublimate  solution 
of  1  to  2,000,  and  iodoform  gauze  was  placed  over  each  wound,  though 
so  lightly  that  urine  could  readily  flow  through  the  dressing.  The 
progress  of  the  case  was  in  every  way  most  satisfactory,  the 
patient  making  a  complete  recovery,  and  leaving  the  hospital  on 
December  24th." 

Penetration  of  the  bladder  by  sharp  instruments,  or  by  bullets  and 
other  projectiles,  is  occasionally  met  with  in  civil  as  well  as  in  mili- 
tary practice.  An  unusual  instance  of  this  kind  is  recorded  by  Mr. 
Couper.  ^ 

Case.— A  seaman,  aged  23,  was  admitted  into  the  London  Hos- 
pital on  April  26th,  with  a  small  incised  wound  of  the  left  buttock.  He 
had  been  stabbed  in  a  quarrel,  with  a  sailor's  long  knife.  He  walked 
into  the  receiving  room,  but  with  difficulty ;  was  blanched,  and  in  a 
condition  approaching  collapse.  From  the  state  of  his  clothing  it  was 
evident  that  he  had  lost  a  great  deal  of  blood.  The  wound  was  about 
one  inch  long,  was  clean  cut,  and  situated  exactly  in  the  middle  of 
the  left  buttock.  The  finger  introduced  into  the  wound  passed  for 
some  depth  in  the  direction  of  the  great  sciatic  notch,  which  could  be 
felt.  Shortly  after  admission  he  passed  his  water ;  it  was  clear,  and 
contained  no  blood.  Next  day,  the  patient  appeared  quite  comfort- 
able, and  had  no  difl&culty  with  his  water,  which  was  passed  at  usual 
intervals  and  was  normal.  April  28th.  Patient  vomited  several 
times ;  complained  of  pain  over  abdomen ;  became  restless.  Tempera- 
ture at  night  104°.  Symptoms  of  acute  peritonitis  now  became  more 
apparent,  and  death  took  place  on  May  1st.  Throughout  he  never 
had  trouble  with  his  bladder. 

At  the  post-mortem  examination  the  knife  was  found  to  have  taken 
the  following  course :   It  had  i^enetrated  the  gluteal  muscles,  divided 


KUPTUEE  AND   INJURIES  OF  THE  BLADDER,  211 

a  part  of  the  great  sacro-sciatic  ligament,  and  passed  through  the 
small  sacro-sciatic  notch,  completely  dividing  the  pudic  artery  and 
nerve  and  one  vein.  Each  end  of  the  artery  was  perfectly  closed  by  a 
little  clot.  The  knife  had  then  entered  the  bladder  at  its  lower  part, 
and  close  to  the  trigone,  making  a  wound  large  enough  to  admit  the 
tip  of  the  forefinger.  There  was  diffuse  suppuration  of  the  cellular 
tissue  of  the  pelvis  and  general  acute  peritonitis. 

The  case  is  interesting  as  illustrating  the  complication  which, 
from  the  symptoms,  there  were  no  grounds  for  suspecting,  post-mor- 
tem examination  alone  revealing  it. 

In  cases  of  incised  wounds,  where  there  is  a  suspicion  of  evidence 
that  the  bladder  is  wounded,  it  is  probably  better  to  allow  the  urine 
to  drain  off  by  a  catheter,  passed  either  through  the  wound  or  along 
the  urethra,  whichever  way  the  urine  flows  the  more  freely,  rather 
than  permit  of  it  being  voluntarily  discharged  by  the  bladder.  In 
wounds  of  the  anterior  wall  of  the  bladder,  the  experience  of  supra- 
pubic incisions  made  for  surgical  purposes,  and  suicidally,  seems  to 
indicate  that  the  best  plan  is  to  leave  the  wound  to  granulate,  pro- 
vided the  urethra  is  not  strictured.  In  the  latter  case,  perineal  punc- 
ture for  drainage,  with  division  of  the  contraction,  might  be  required. 

Sir  William  Stokes"  records  the  particulars  of  a  remarkable  case 
where  one  of  the  long  handles  of  a  pair  of  iron  tongs,  over  which  a 
boy  was  vaulting,  entered  4he  rectum  and  passed  through  the  bladder 
into  the  peritoneal  cavity.  The  viscus  was  consequently  ruptured  in 
two  places.     Death  followed  in  seventy-four  hours  from  peritonitis. 

Gunshot  wounds  involving  the  bladder,  though  requiring  treatment 
on  general  principles,  belong  to  a  branch  of  surgery  of  which,  as 
civilians,  we  see  but  little.  Every  variety  of  this  kind  will  be  found 
illustrated  in  a  work  which  modern  warfare  '°  has  provided  us  with. 
A  foreign  body  which  has  found  its  way  directly  into  the  bladder,  or 
indirectly  by  ulceration  or  sloughing,  may  serve  as  a  nucleus  for  the 
formation  of  stone ;  of  this  we  have  instances,  in  the  work  referred 
to,  of  concretions  forming  on  arrow-heads,  as  used  by  the  Indians, 
on  bullets  and  other  projectiles,  on  pieces  of  bone,  or  on  the  debris  of 
a  fractured  pelvis  which  have  found  their  way  into  the  bladder.  Por- 
tions of  clothing,  buttons,  and  other  articles  of  dress,  have  also  be- 
come covered  with  phosphatic  concretions.  In  all  cases  of  gunshot 
injuries  involving  the  urinary  apparatus  care  should  be  taken,  either 
by  catheterism  or  incision,  to  provide  for  escape  of  the  urine,  as  its 
collection  in  the  locality  of  extravasated  blood  or  damaged  tissue  is 
a  certain  cause  of  destructive  inflammation.  We  should  also  not  neg- 
lect to  ascertain  by  the  use  of  a  sound  if  any  foreign  body  is  lodged  in 
the  bladder. 


212  HAERISON — DISEASES  OF  THE  BLADDER. 

It  is  asserted  that  rupture  of  tlie  bladder  may  occur  without  ex- 
travasation of  urine  ensuing  as  a  consequence.  I  do  not  see  what 
positive  evidence  of  this  can  be  afforded;  the  nature  of  the  injury 
and  hsematuria  may  possibly  suggest  it,  but  this  is  about  all  that  can 
be  said.  If  it  were  suspected  that  a  slight  rupture  had  taken  place, 
which  by  some  means  or  other — such,  for  instance,  as  the  presence 
of  a  clot  in  the  wound,  its  valvular  form,  or  the  exudation  of  inflam- 
matory material — -had  become  occluded,  I  should  not  feel  disposed 
either  to  pass  a  catheter,  provided  there  was  no  retention,  or  to  retain 
one,  I  would  sooner  trust  to  Nature  completing  a  task  she  had  com- 
menced so  well,  aiding  her,  perhaps,  in  keeping  the  parts  quiet  and 
the  skin  active  by  the  internal  administration  of  opium. 

The  power  of  a  patient  voluntarily  to  expel  his  urine  is  occasion- 
ally temporarily  suspended  in  connection  with  injuries  to  the  trunk. 
Retention  of  urine  not  unfrequently  follows  concussion  of  the  spine. 
Power  usually  returns  in  the  course  of  forty-eight  hours,  and,  so  far 
as  this  symptom  is  concerned,  nothing  further  than  regular  catheter- 
ism  is  required.  In  courts  of  law  imperfect  power  in  micturition  is 
sometimes  referred  to  as  a  symptom  of  spinal  concussion.  When  it 
immediately  follows  an  injury  and  disappears,  it  need  not  create  ap- 
prehension, as  it  is  only  in  keeping  with  the  other  signs  of  nerve 
shock.  If  it  occurs  after  a  lapse  of  time,  and  is  consequent  upon  an 
injury,  its  import  is  grave,  as  it  is  probably  connected  with  structural 
changes  in  the  nerve  centre  controlling  the  action  of  the  bladder.  Re- 
tention of  urine  happens  in  connection  with  violent  contusions,  such 
as  crushes  involving  the  abdominal  muscles.  The  inability  of  the 
latter  to  co-operate  with  the  bladder  in  the  expulsion  of  urine,  with- 
out causing  pain,  is  sufficient  to  explain  this,  and  does  not  require 
any  special  treatment  beyond  the  use  of  the  catheter  until  normal 
function  returns.  '  . 

FOREIGN  BODIES  IN  THE  BLADDER. 

By  accident  or  design  foreign  bodies  occasionally  become  lodged 
within  the  bladder.  Among  the  miscellaneous  articles  that  have 
been  found  in  this  position  I  can  recall  to  mind  pins,  needles,  wires, 
a  lucifer  match,  a  knitting-needle,  a  slate-pencil,  a  feather,  a  bulb- 
headed  grass,  pieces  of  catheters  and  bougies,  a  whole  bougie,  and  a 
pencil-case ;  but,  taking  the  experience  of  others,  this  list  might  be 
considerably  extended.  Most  of  these  things  have  been  introduced 
for  the  purpose  of  acting  upon  the  penile  portion  of  the  urethra — for 
reasons  best  known  to  the  patients  themselves — and  have  subsequently 
made  their  way  into  the  bladder.     In  reference  to  the  movements  of 


FOREIGN  BODIES  IN  THE  BLADDER.  213 

foreign  bodies,  my  impression  is  tliat  the  vermicular  action  of  the 
urethra  is  an  ejaculatory  one,  and  that  such  a  body  is  only  forced  to- 
ward the  bladder  when  in  its  form  it  presents  an  obstacle  to  its  out-  • 
ward  passage.  A  piece  of  bougie,  with  its  anterior  extremity  broken 
and  uneven,  and  its  posterior  end  smooth,  placed  in  the  urethra,  is 
sure  by  the  vermicular  action  of  the  canal  to  be  forced  in  a  direction 
toward  the  bladder  by  the  effects  that  are  made  to  expel  it.  I  will 
mention  some  cases  where  foreign  bodies  have  been  passed  into  the 
urethra,  as  serving  to  illustrate  certain  points  in  practice. 

Case.— In  1861,  I  saw  a  youth,  aged  16,  who  was  suffering  from 
some  induration  in  the  ischio-rectal  fossa  and  perineum.  On  in- 
quiring into  his  history,  it  was  found  that  eighteen  months  previously 
the  patient  had  passed  into  his  urethra  a  needle,  which,  having  slipped 
from  his  grasp,  disappeared.  Not  liking  to  mention  it,  he  refrained 
from  seeking  surgical  advice.  He  appears  to  have  suffered  very  little 
inconvenience  up  to  within  a  week  from  his  being  seen,  when  he  had 
pain  about  the  perineum  and  difficulty  in  micturition.  As  fluctuation 
could  be  felt  in  the  ischio-rectal  fossa,  an  incision  was  made,  and  some 
matter  evacuated,  but  no  needle  was  discovered  until  the  finger  was 
passed  into  the  rectum,  when  the  sharp  point  presented  in  front.  A 
median  perineal  opening  was  made  and  the  foreign  body  removed.  It 
was  largely  encrusted  with  a  deposit  of  phosphates.  The  patient  re- 
covered rapidly,  no  urine  escaping  through  either  of  the  incisions. 

Mr.  Mitchell  Banks  has  given  me  the  particulars'  of  a  case  he  had 
seen  where  a  needle  had  been  passed  up  the  urethra  by  a  boy  three 
days  previously.  On  examining  by  the  rectum  he  could  feel  the  blunt 
end  of  the  foreign  body,  and  was  able  to  force  the  point  through  the 
perinseum  and  thus  to  extract  it.  In  the  following  instance  I  removed 
from  the  bladder  of  a  middle-aged  man  a  bougie,  twelve  inches  in 
length : 

Case. — The  bougie  had  been  introduced  by  a  surgeon  as  a  guide 
to  a  urethrotome,  with  which  it  was  intended  to  divide  a  stricture  by 
internal  section.  Unfortunately  the  bougie  separated  from  the  ure- 
throtome just  beyond  the  point  where  it  was  attached  by  means  of  a 
screw.  The  surgeon  at  once  divulsed  the  stricture  by  Holt's  method, 
and  left  the  bougie  in  the  bladder  for  extraction  on  a  future  occasion. 
I  saw  the  case  fourteen  days  after  the  accident.  As  the  urethra  would 
by  this  time  admit  a  No.  l2  bougie,  I  had  no  difficulty  in  introducing 
the  lithotrite  and  extracting  the  bougie,  which  I  seized  about  the  cen- 
tre and  brought  out  doubled ;  it  being  soft  and  of  small  size,  the  re- 
moval was  accomplished  by  merely  gentle  traction.  The  patient  re- 
covered without  a  bad  symptom.  The  bougie  appears  to  have 
remained  curled  up  in  the  bladder ;  no  calculous  deposit  was  observed 
upon  it,  although  it  had  been  retained  for  a  fortnight. 

It  is  possible  that  the  extraction  of  long  bodies  offering  greater 
resistance,  such  as  thicker  catheters  and  bougies,  might  be  facilitated 


214 


HAERISON — DISEASES   OP  THE  BLADDER. 


by  first  dividing  them  with  Caudemont's  cutting  litliotrite,  and  then 
extracting  them  in  portions.  The  case  just  narrated  points  to  the  ne- 
cessity of  care  being  exercised  in  properly  securing  the  connecting 
links  between  urethral  instruments  and  the  guides  now  so  frequently 
used  in  connection  with  them. 

Among  the  more  remarkable  objects  that  have  found  their  way 
into  the  bladder  is  a  bulbous  grass,  as  in  the  following  case : 

Case.^ — A  middle-aged  man  came  into  the  Liverpool  Infirmary  in 
1865,  under  the  care  of  Mr.  Long.     The  patient  supposed  he  was 

suffering  from  stricture,  to  remedy 
which  he  was  in  the  habit  of  passing 
different  materials  into  his  urethra. 
On  this  occasion  he  selected  the  ear 
and  stalk  of  one  of  the  grasses,  which 
was  introduced  readily  enough,  but 
could  not  be  withdrawn.  When  ad- 
mitted shortly  after  the  accident,  he 
was  suffering  from  most  acute  cysti- 
tis. A  lithotrite  removed  a  portion 
of  the  grass-head,  slightly  encrusted 
with  phosphates,  but  the  symptoms 
were  not  abated,  and  death  resulted. 
On  opening  the  abdomen  general 
peritonitis  was  found,  with  four  or 
five  pints  of  turbid  serum,  which  ex- 
haled an  ammoniacal  odor.  The 
bladder  contained  (Fig.  34)  a  head  of 
one  of  the  grasses,  covered  with  phos- 
phatic  deposit.  The  stalk,  which  was 
stiff  and  resisting,  had  made  its  way 
through  the  fundus  of  the  bladder, 
and  protruded  into  the  peritoneal 
ca^dty.  The  pelvic  cellular  tissue  was 
infiltrated  with  purulent  matter,  hav- 
ing a  urinous  odor,  and  the  inflam- 
mation extended  up  the  ureters  to 
the  kidneys.  The  history  of  the  case  was  obtained  at  first  not  with- 
out difficulty,  and  what  had  actually  been  inserted  into  the  urethra 
was  a  matter  for  speculation,  which  the  introduction  of  the  lithotrite 
only  incompletely  determined. 

The  following  case,  analogous  with  the  preceding,  illustrates  the 
value  of  the  electric  cystoscope  where  foreign  bodies  of  a  soft  nature 
are  passed  into  the  bladder,  and  cannot  be  felt  with  any  instrument : 

Case. — A  middle-aged  man  applied  at  St.  Peter's  Hospital  in 
1892,  stating  that  he  had  put  a  piece  of  grass  up  his  urethra  a  week 
previously,  and  believed  it  was  now  lodged  in  his  bladder.  I  passed 
a  sound,  but  feeling  nothing,  endeavored  to  withdraw  the  foreign 
body  through  a  large  evacuating  catheter  by  suction  with  an  aspira- 


FlG.  34. 


-Bladder  Containing  a  Head  of 
Grass. 


FOREIGN  BODIES  IN  THE  BLADDER.  215 

tor,  witlioTit  avail.  It  tlien  occurred  to  me  to  use  the  cystoscope,  and 
Mr.  Hurry  Fenwick,  who  was  present,  passed  it  at  my  request.  By 
means  of  this  instrument  those  who  were  with  me  were  able  to  see  a 
branched  piece  of  grass  lying  on  the  right  base  of  the  bladder.  It 
was  then  an  easy  matter  for  me  to  seize  and  extract  it  with  the  litho- 
trite.  The  patient  left  the  hospital  on  the  following  day,  none  the 
worse  for  his  escapade. 

Suction,  with  a  large-eyed  evacuating  catheter  and  an  aspirator 
bottle,  as  used  for  lithotrity,  is  an  efficient  means  for  extracting  some 
foreign  bodies  of  a  yielding  nature.  I  have  recorded  an  instance  " 
where  a  man  passed  a  long  piece  of  bacon  rind  up  his  urethra,  and 
some  days  afterward  a  stiff  pig's  bristle  several  inches  in  length. 
Symptoms  of  bladder  irritation  supervening,  I  adopted  this  method, 
and  feeling  something  engaged  in  the  eye  of  the  catheter,  after  a  few 
movements  of  the  water  in  the  syringe,  I  withdrew  it  together  with  the 
bristle  which  the  catheter  contained.  Nothing  was  seen  of  the  ba- 
con, which  was  either  dissolved  or  expelled,  as  after  what  was  done 
all  further  symptoms  of  bladder  irritation  disappeared. 

In  1864,  a  case  was  related  at  the  Liverpool  Medical  Society,  by 
Mr.  Robert  Hamilton,  where  he  had  removed  from  a  man's  bladder 
portions  of  calculous  concretion  formed  on  a  feather,  which  had  been 
passed  by  the  patient  for  the  relief  of  stricture.  Here  lithotomy  was 
performed,  as  from  the  nature  of  the  stricture  lithotrity  was  hardly 
possible. 

In  the  following  instance  a  foreign  body  was  removed  from  the 
bladder  by  means  of  the  lithotrite : 

Case. — W.  O.,  aged  38,  a  militiaman,  was  admitted  into  the  Liver- 
pool Infirmary  on  May  22d,  1877,  when  I  was  attached  to  that  insti- 
tution. His  statement  was  to  the  effect  that  on  the  previous  night, 
when  under  the  influence  of  liquor,  a  pencil-case  had  been  introduced 
up  his  urethra  by  a  prostitute,  in  whose  company  he  had  been.  He 
did  not  appear,  however,  to  have  discovered  anything  amiss  until  the 
following  morning,-  when  certain  uncomfortable  sensations  in  the  re- 
gion of  his  bladder  made  him  come  to  the  conclusion  that  the  lost 
pencil  must  be  there.  From  his  manner  I  was  at  first  inclined  to 
think  the  man  was  insane,  but  on  hearing  that  the  surgeon  of  his 
regiment  had  discovered  a  foreign  body  in  his  bladder,  and  had  sent 
him  to  the  Infirmary,  I  at  once  examined  him.  Upon  doing  so  with 
a  sound,  the  foreign  body  appeared  to  be  lying  obliquely,  partly  in  the 
bladder  and  partly  within  the  prostatic  urethra.  I  first  attempted  to 
remove  it  by  the  extractor,  described  in  Eeliquet's  "Traite  des 
Operations  des  Voies  Urinaires,"  and  known  as  the  instrument  of 
Messrs.  Robert  and  Collin,  but  failing,  a  lithotrite  was  passed.  By 
this  the  pencil  was  carried  on  completely  within  the  bladder,  where 
it  was  seized  transversely.  In  this  position  it  was  impossible  to  ex- 
tract it ;  however  by  gradually  rotating  the  lithotrite  toward  one  side, 


216 


HARRISON — ^DISEASES  OF  THE  BLADDER. 


while  the  pencil  was  within  the  blades  of  the  instrument,  I  succeeded 
in  reaching  one  end,  when  the  pencil  was  removed,  point  foremost, 
without  any  further  difficulty  or  damage  to  the  urethra.     The  exact 


Fig.  35.— Pencil-Case  Removed  From  the  Bladder.    Actual  size. 

size  of  the  pencil-case  is  represented  in  Fig.  35.  The  patient  soon 
passed  urine  naturally,  and  on  the  following  day  appeared  in  no  re- 
spect the  worse  for  what  had  been  done. 

The  difficulty  in  removing  foreign  bodies,  such  as  pieces  of  bougie, 
from  the  bladder  is  due  to  their  being  seized  transversely  by  for- 
ceps or  the  lithotrite.  This  difficulty  Messrs.  Robert  and  Collin  have 
endeavored  to  overcome  by  the  use  of  an  instrument  something  like 
a  lithotrite  (Fig.  36) ,  the  blades    of  which  are  so  arranged  that,  on 


Fig.  36.— Extractor  of  Foreign  Bodies  of  Oblong  Shape. 


seizing  a  body,  such  as  a  piece  of  bougie,  it  is  rotated  and  its  long 
axis  is  made  to  correspond  with  the  course  of  the  urethra.  The  blad- 
der should  be  partly  distended  with  water  before  the  extractor  is 
introduced. 

Perhaps  more  remarkable  than  the  instance  of  the,  pencil-case  just 
recorded,  is  one  where  I  removed  by  cystotomy  the  whalebone  mouth- 


FiG.  37. — stem  of  Tobacco-Pipe  Removed  from  the  Bladder. 

pieceof  a  tobacco-pipe  (Fig.  37),  encrusted  with  phosphates.  As  to 
how  the  foreign  body  got  into  the  bladder  the  patient  must  speak  for 
himself. 

Case. — E.  H.,  aged  33,  a  seaman,  was  admitted  into  the  Liverpool 
Eoyal  Infirmary  on  June  23d,  1884,  suffering  from  symptoms  of  ves- 
ical irritation.  The  history  showed  that  eight  years  previously  he 
had  had  gonorrhoea,  and  more  recently  he  was  admitted  into  a  hospital 


FOREIGN  BODIES  IN  THE  BLADDEB.  217 

in  Wales  witli  a  fractured  leg.  I  found  him  suffering  from  stone  in 
the  bladder.  Upon  examining  the  calculus  with  the  lithotrite  it 
proved  to  be  large,  soft,  and  peculiarly  shaped.  The  last-mentioned 
circumstance  determined  me  to  cut  instead  of  crushing.  On  June 
27th,  I  performed  lateral  lithotomy,  and  removed  a  phosphatic  calcu- 
lus, which  broke  under  the  grasp  of  the  forceps  and  disclosed  the 
whalebone  mouthpiece  of  a  tobacco-pipe,  to  which  a  small  piece  of 
rotten  string  was  attached.  It  was  noticed  that  the  smell  of  tobacco 
in  the  mouthpiece  was  distinct.  As  the  phosphatic  envelope  crum- 
bled under  the  pressure  of  extraction,  it  was  impossible  to  estimate 
correctly  its  weight.  It  must  have  been  very  large.  About  an  ounce 
of  these  fragments  was  collected  and  weighed.  The  exact  size  of  the 
mouthpiece  is  shown  in  the  drawing  (Fig.  37) .  The  patient  made  a 
good  recovery,  and  left  the  Infirmary  on  July  28th.  After  the  opera- 
tion I  showed  him  the  foreign  body,  and  asked  whether  he  could  offer 
any  explanation  as  to  how  it  got  into  his  bladder.  He  remarked  that 
"he  was  glad  to  see  it  again."  He  had  swallowed  it  while  larking 
with  some  companions  on  board  ship  three  years  ago.  He  felt  no 
pain  at  the  time,  nor  until  December,  1883,  when  the  symptoms  of 
something  wrong  with  his  bladder  showed  themselves.  He  was  fre- 
quently spoken  to  with  reference  to  the  improbability  of  such  an  ex- 
planation, but  he  would  never  admit  of  any  other  construction  being 
placed  on  the  word  "  swallowed"  than  that  usually  adopted.  The  case 
is  also  an  important  one  as  indicating  a  source  of  fallacy  and  of  dan- 
ger in  some  cases  of  crushing  we  undertake. 

A  case  is  published '°  where  a  piece  of  stick  covered  with  prickles 
(Fig.  38)  was  introduced  up  the  ure- 
thra of  a  male  in  such  a  way  as  to 

render    it    impossible  to  draw    it   out     Fig.  38.— Prickly  stick  Removed  from  the 

without  subjecting  the  canal  to  lac-  ^^   ^^' 

eration.    I  quote  the  following  from  the  record  by  Dr.  G.  A.  Harris : 

"  It  transpired  on  inquiry  that  three  brothers,  not  quite  approving 
of  the  attention  paid  by  my  patient  to  one  of  their  female  relatives, 
took  counsel  together,  and  waylaying  him  in  the  jungle  at  night,  over- 
powered him,  and  deliberately  introduced  two  and  a  half  inches  of 
thorny  cane  into  his  urethra,  well  knowing  from  the  disposition  of 
the  thorns  on  the  stem  that  it  would  be  extremely  difficult,  if  not  im- 
possible, for  the  victim  himself  to  remove  it,  and  that,  in  any  case,  ex- 
treme suffering  would  result ;  a  powerful  moral  hint  being  at  the  same 
time  inculcated  in  a  way  that  would  insure  its  being  remembered 
through  life.  I  gently  pushed  the  stick  back  until  I  judged  all  the 
thorns  had  become  disentangled,  and,  with  some  little  trouble,  suc- 
ceeded in  passing  a  canula  over  it,  and  withdrew  the  piece  of  stick 
easily  through  the  canula." 

In  the  majority  of  instances  the  history  and  circumstance  connected 
with  the  introduction  of  foreign  bodies  into  the  bladder  are  vague, 
and  the  practitioner  has  often  little  to  guide  him  in  the  treatment  of 
the  acute  symi^toms  of  cystitis,  and  subsequently  of  i)eritonitis,  which 


218  HAEEISON — DISEASES  OF  THE  BLADDER. 

supervene.  In  tlie  example  previously  recorded  and  figured  (page 
214) ,  where  a  grass-head  was  passed  into  the  bladder  and  caused  death 
by  perforation  and  peritonitis,  nothing  would  have  saved  the  patient, 
even  had  it  been  possible  to  make  a  full  diagnosis,  in  the  absence  of 
a  correct  history,  at  the  time  he  was  admitted  into  hospital,  but  a 
supra-pubic  cystotomy  with  closure  of  the  perforation  into  the  abdo- 
men by  sutures,  as  is  now  done  in  the  case  of  a  ruptured  bladder. 
The  study  of  cases  and  pathological  records  where  foreign  bodies 
have  been  introduced  into  the  bladder,  both  in  males  and  females,  in- 
dicates that  in  many  not  only  was  their  removal  by  operation  impera- 
tive, but  that  the  method  selected  should  have  been  of  a  nature  to 
permit  the  inspection  and  exploration  of  the  whole  of  the  interior  of 
the  viscus,  with  the  view  of  ascertaining  whether  such  damage  was 
occasioned  by  the  pressure  of  the  foreign  body  as  to  render  a  perfo- 
ration imminent.  If  this  were  the  case  in  a  given  instance,  a  lapar- 
otomy must  necessarily  supervene  upon  a  cystotomy.  The  high 
operation  would  alone  permit  of  our  applying  such  an  examination 
and  treatment  to  the  bladder,  if  perforated  or  on  the  verge  of  perfora- 
tion, as  we  should  to  the  intestine  if  similarly  involved.  Instances 
will  be  found  recorded  where,  though  foreign  bodies  were  removed 
by  perineal  cystotomy,  the  patients  eventually  died  of  perforation 
and  peritonitis. 

Where  there  exist  reasons  for  believing  that  a  foreign  body  of  some 
size  or  of  irregular  shape,  more  or  less  covered  with  phosphates,  is  con- 
tained within  the  bladder,  and  may  possibly  be  on  the  verge  of  pene- 
trating it,  as  has  happened,  it  is  better  to  proceed  with  a  supra-pubic 
cystotomy  for  the  purpose  of  effecting  its  removal  in  what  appears  to 
be  the  safest  as  well  as  the  most  complete  manner.  Dr.  Gillon  "  re- 
ports a  case  where  he  removed  succcessfully  a  phosphatic  calculus 
weighing  nearly  three  ounces,  including  the  nucleus  which  was  a 
bone  penholder  over  five  inches  in  length,  by  a  supra-pubic  cystot- 
omy. The  body  was  lying  obliquely  across  the  bladder,  and  to  ex- 
tract it,  it  was  necessary  to  divide  the  penholder  with  a  pair  of  bone 
forceps.  Any  other  method  of  effecting  extraction  would  probably 
have  resulted  in  a  rupture  of  the  bladder  and  the  death  of  the  patient, 
who  was  an  artisan,  aged  forty -three. 

Among  the  more  remarkable  instances  where  foreign  bodies  have 
been  introduced  into  the  bladder  and  have  perforated  it,  is  one  re- 
corded conjointly  by  Dr.  Benham  and  Mr.  Greig  Smith,"  where  the 
end  of  an  iron  umbrella  rib  was  found  in  contact  with  the  intestines. 
The  specimen  as  shown  in  the  drawing  (Fig.  39)  was  discovered  after 
death  in  the  body  of  a  demented  male  epileptic.     It  is  remarked : 

"  In  this  case  the  foreign  body  passed  through  the  bladder  into 


FOREIGN  BODIES   IN  THE   BLADDER. 


219 


the  peritoneal  cayity  for  tlie  distance  of  two  inches,  apparently  with- 
out doing  any  harm.  Phosphatic  deposit  was  laid  down  on  the  metal 
in  slight  amount  for  half  an  inch  outside  the  bladder,  and  this  sug- 
gests that  the  walls  of  the  bladder, 
as  it  filled  and  emptied,  slipped  up 
and  down  the  instrument,  giving 
opportunity  of  only  intermittent 
incrustation.  It  is  nothing  short 
of  marvellous  that  no  escape  of 
urine  into  the  peritonaeum  should 
have  taken  place." 

Dr.  Poulet'^  seems  to  conclude 
that  such  cases  of  perforation  are 
necessarily  and  speedily  fatal. 

The  publication  of  the  case  of 
the  tobacco-pipe'*  previously  re- 
ferred to  led  to  my  receiving  several 
interesting  letters  from  practition- 
ers in  reference  to  the  difficulty  of 
diagnosis  in  cases  of  this  nature. 
Among  these  letters  was  one  from 
Mr.  J.  H.  Wilson,  of  Thetford,  who 
refers  to  a  case  successfully  oper- 
ated on  by  Mr.  Cadge  by  lithotrity, 
where  the  nucleus  of  the  phosphat- 
ic mass  in  the  bladder  turned  out 
to  be  a  boot-lace.  Having  antici- 
pated that  he  had  to  deal  with  a 
foreign  body,  Mr.  Cadge  writes: 
"My  suspicions  turned  out  to  be 
correct,  for  I  have  removed,  at  four 
or  five  sittings,  with  the  lithotrite, 
six  or  seven  inches  of  a  black  thing 
which  I  believe  to  be  a  common 
boot-lace,  covered  with  phosphates. 
Even  with  this  evidence,  the  fellow 
will  not  admit  to  having  introduced  it,  or  allowed  any  one  else  to  do 
so."  Mr.  Wilson  adds:  "Like  your  patient,  mine  remembered,  after 
a  stretch  of  memory,  having  swallowed  a  boot-lace."  These  cases  are 
of  value,  as  I  said  before,  as  illustrating  difficulties  in  diagnosis 
which,  without  such  examples,  we  might  hardly  expect  to  meet.  If 
patients  will  not  tell  us,  or  do  not  of  themselves  know,  that  they  have 
pencil-cases,  pipe-stems,  and  boot-laces  in  their  bladders,  we  cannot 
always  be  expected  to  enlighten  them  at  once  upon  this  point. 


Fig.  39.— Umferella  Rib  Passing  Through  the 
Wall  of  the  Bladder.  A  calculus  had  formed 
about  the  end  of  the  rib  in  the  bladder,  and 
there  is  also  a  phosphatic  deposit  for  a  short 
distance  along  the  metal  outside  of  the 
bladder. 


220  HAEEISON — DISEASES  OF  THE  BLADDER. 

In  using  the  litliotrite  for  ihe  removal  of  pliosphatic  calculi  formed 
on  a  foreign  body,  it  must  not  be  forgotten  that  tlie  latter  is  some- 
times of  sucli  a  nature  as  actually  to  entangle  the  jaws  of  the  litho- 
trite  and  to  impact  them.  This  has  happened  with  a  hair-pin  and 
the  noose  of  a  wire  suture,  which  found  their  way  into  the  bladder 
and  formed  the  nuclei  for  stones.  Mr.  E.  E.  Dorr  records  a  case  " 
where  a  man  had  passed  up  his  urethra  a  piece  of  chewing-gum, 
which,  in  three  months,  became  largely  coated  with  phosphates.  It 
was  successfully  removed  by  the  supra-pubic  method.  It  is  noted : 
"It  would  have  been  impossible  either  to  have  crushed  the  gum, 
which  was  still  soft  and  sticky,  or  to  have  disengaged  the  jaws  of  the 
lithotrite."  Two  instances  have  recently  been  recorded  where  paraffin 
was  injected  into  the  urethra,  and  subsequently  concreted  in  the  blad- 
der. One  occurred  in  the  practice  of  Mr.  David  Wallace,'**  and  the 
other  in  that  of  Mr.  Buckston  Browne. '"  We  are  reminded  that  an 
article  of  this  nature  floats  on  the  urine  or  upon  any  fluid  the  bladder 
may  contain. 

Mr.  H.  C.  Garde  records  an  instance'^"  where  a  man  pushed  a 
threepenny-piece  into  his  urethra,  which,  in  the  course  of  six  weeks, 
worked  its  waj^  into  the  bladder.  It  was  successfully  extracted  by  the 
lithotrite,  though,  it  is  stated,  "more  than  half  the  coin  projected 
from  the  side  of  the  instrament. " 

In  connection  with  the  passage  of  stones  from  the  kidney  down 
the  urethra,  it  has  been  noticed  that  their  expulsion  from  the  latter 
canal  is  often  much  facilitated  by  the  patient,  when  feeling  that  he  is 
about  to  void  one,  closing  the  meatus  for  a  moment  on  commencing 
to  urinate,  so  as  to  obtain  the  full  dilating  power  of  the  urine. 

Referring  to  the  escape  of  foreign  bodies  from  the  intestines  to  the 
bladder,  it  will  be  desirable  to  notice  those  cases  where  there  can  be 
but  little  doubt  that  this  has  happened.  We  may  put  aside,  as  not 
bearing  upon  the  subject,  those  instances  of  malignant  ulceration 
where  the  bladder  and  intestines  are  thrown  into  one  chasm,  and  a  free 
interchange  of  their  respective  contents  takes  place.  These  examples 
will  again  come  under  notice  in  connection  with  the  subject  of  malig- 
nant affections  of  the  bladder  and  their  treatment.  Sir  Alfred  Rob- 
erts, of  the  Sydney  Hospital,  N.  S.  W.,  records  one  where  the  patient, 
forty-seven  years  of  age,  had  swallowed  a  piece  of  slate-pencil  two  and 
a  quarter  inches  long,  which  was  subsequently  successfully  removed 
from  the  bladder  by  lithotomy.  Commenting  upon  this,  the  author 
says :  "  I  have  left  no  stone  unturned  to  elucidate  the  truth  in  this  in- 
teresting case,  and  I  can  only  state  that,  after  much  hesitation,  I  have 
arrived  at  the  conclusion  that  the  pencil  was  swallowed  by  mouth, 
and  made  its  way  by  inflammation  and  ulceration  into  the  bladder."" 


:  FOREIGN    BODIES   IN   THE   BLADDEIl.  221 

A  case  is  recorded  by  Mr.  Brownhill  where  a  woman,  aged  26, 
passed  spontaneously  by  tlie  urethra  a  stone  weighing  over  half  an 
ounce,  the  nucleus  of  which  was  a  hair-pin.  Twenty -seven  months 
previously,  when  she  was  straightening  her  hair  with  the  pin  in  her 
mouth,  one  of  her  companions  pulled  her  hair  from  behind,  causing 
her  to  laugh  and  throw  her  head  back,  when  the  pin  slipped  down  the 
oesophagus.  It  was  considered  probable  that  the  pin  passed  from 
the  sigmoid  flexure  of  the  colon  into  the  left  side  of  the  bladder." 

Passing  to  circumstances  which  arise  out  of  more  every-day  expe- 
riences, the  following  case  presents  points  of  considerable  interest : 

Case. — A  gentleman,  about  50  years  of  age,  was  referred  to  me  by 
Dr.  J.  Cameron,  of  Liverpool,  in  Ajml,"  1882,  with  a  note  that  there 
was  a  formation  or  tumor  about  the  base  of  the  bladder  which  was 
palpable  to  the  touch.  His  history  pointed  to  intestinal  irritation 
of  some  months'  standing.  For  six  weeks  he  had  suffered  more  or 
less  from  diarrhoea  and  irritability  of  the  bladder,  accompanied  with 
considerable  abdominal  pain.  His  urine  contained  pus  and-  air  bub- 
bles, and  he  noticed  that  micturition  terminated  with  a  sort  of  fizzing 
noise.  There  was  considerable  swelling  corresponding  with  the  fun- 
dus of  the  bladder.  The  mass  was  about  as  large  as  a  tennis  ball, 
and  felt  like  a  scirrhus.  A  sound  passed  into  the  bladder  detected 
nothing  abnormal.  The  urine  was  found  to  contain  pus,  air  globules, 
and  particles  of  food.  About  a  fortnight  after  I  saw  him  the  patient 
reported  himself  as  better,  both  the  swelling  and  irritability  of  the 
bladder  being  less.  The  urine  at  times  was  colored  with  fsecal 
matter  and  contained,  by  the  microscope,  some  elements  of  food.  He 
stated  that  he  had  recently  passed  with  some  trouble,  by  the  ure- 
thra, a  mass  about  three-quarters  of  an  inch  long  which  he  thought 
was  a  stone.  This  proved  to  be  the  end  of  a  rabbit's  thigh  bone, 
which  no  doubt  was  swallowed,  and  was  the  key  to  the  whole  case. 
After  this  he  began  to  improve,  the  swelling  disappeared,  and  he 
rapidly  convalesced  and  resumed  his  business.  He  has  since  enjoyed 
good  health,  but  at  times  he  is  conscious  of  a  little  escape  of  wind 
into  the  bladder,  and  when  his  bowels  are  much  relaxed  there  is  also 
some  faecal  matter.  Probably  the  fistulous  communication  has  never 
completely  closed." 

When  the  case  first  came  under  my  notice  it  seemed  to  present  al- 
most every  feature  usually  associated  with  a  malignant  abdominal 
growth.  Had  I  then  committed  myself  to  a  diagnosis  I  hardly  see 
how  this  conclusion  could  have  been  avoided.  The  progress  of  the 
case  and  the  lapse  of  time,  however,  indicated  that  such  could  hardly 
have  been  so,  though  the  age  of  the  patient,  the  gradual  and  ill-de- 
fined character  of  the  early  symptoms,  the  losing  of  flesh,  and  the 
ulcerous  communication  between  the  bladder  and  intestines,  all  seemed 
to  point  one  way  until  the  foreign  body  was  discovered.  How  greatly 
the  difficulties  connected  with  the  case  would  have  been  added  to,  so 


222  HAEKISON — DISEASES   OF  THE  BLADDEE. 

far  as  an  explanation  of  tlie  symptoms  was  concerned,  had  the  bone 
been  allowed  to  leave  the  urethra  without  being  recognized ! 

Dr.  Kenaud,  of  Manchester,  has  communicated  to  me  the  follow- 
ing particulars  of  a  somewhat  similar  case  which  came  under  his  ob- 
servation, where,  on  the  death  of  the  patient  from  other  causes,  an 
examination  of  the  parts  was  made. 

"  Mr.  A. ,  aged  63,  observed  that  his  urine  was  surcharged  with 
amorphous  lithates  for  the  space  of  one  month,  after  which  he  no- 
ticed that  micturition  was  frequently  interrupted  by  an  escape  of  air 
bubbles  through  the  urethra.  Feeling  sceptical,  I  asked  him  to  void 
urine  in  my  presence,  and,  sure  enough,  the  sound  of  air  bubbling 
was  unmistakable.  Two  months  later  I  noticed  that  the  urine  was  a 
good  deal  loaded  with  mucus,  and  that  some  foreign  substance  was 
mixed  up  with  it,  v/hich,  'when  placed  under  a  microscope,  was  found 
to  be  a  mixture  of  granular  cells,  spiral  vessels,  etc.  Nine  months 
after  I  first  saw  the  patient  he  died,  in  consequence  of  gout  and  other 
causes,  of  which  the  symptoms  here  referred  to  did  not  represent  an 
important  element.  The  colon  was  found  adherent  to  the  fundus  of 
the  bladder,  and  some  coils  of  bowel  were  glued  together  by  old  and 
in  one  part  thickened  adhesions.  In  the  latter  a  cherry-stone  was 
found  lodged  in  a  false  diverticulum  or  puriform  sac,  which  communi- 
cated with  the  colon  by  another  opening.  With  this  evidence  before 
me,  I  hardly  hesitated  to  conclude  that  the  granular  cells  noticed  five 
months  ago  represented  part  of  a  disintegrated  kernel  of  cherry-stone 
swallowed  a  long  time  previously." 

The  subject  of  fistula  between  the  bladder  and  the  intestines  will 
again  be  referred  to.  With  illustrations  such  as  these  before  us,  we 
cannot  be  surprised  at  almost  anything  that  may  present  in  the  course 
of  our  examination  of  the  urine.  We  must  not  forget  in  connection 
with  this  remark  that  all  sorts  of  deceptions  have  been  practised  by 
means  of  the  urine.  I  not  only  refer  to  persons,  for  reasons  best 
known  to  themselves,  endeavoring  thus  to  deceive  medical  practition- 
ers, but  to  other  instances  where  deceits  of  this  kind  are  practised  for 
the  purpose  of  legal  fraud.  Practitioners  cannot  be  too  careful,  where 
the  statements  are  of  a  suspicious  nature,  in  seeing  the  urine  passed 
in  their  presence  by  the  patient.  In  one  case  that  incidentally  came 
under  my  notice,  I  feel  sure  an  attempt  was  contemplated  in  a  life 
insurance  examination  to  substitute  the  urine  of  another  person. 
There  was  really  no  cause  for  this,  but  the  individual  referred  to  had 
been  victimized  by  quacks,  who  had  succeeded  in  extracting  a  con- 
siderable sum  of  money  on  the  ground  that  he  was  passing  his  semen 
unnaturally,  and  I  believe  he  merely  felt  ashamed  of  the  nature  of  his 
alleged  complaint.  However,  the  case  had  its  lesson  in  more  ways 
than  one. 

The  female  bladder  is  occasionally  found  to  contain  various  for- 


rNFLAMMATION  OF  THE  BLADDER.  223 

eign  bodies  of  a  nature  peculiar  to  the  sex.  Some  years  ago,  by 
means  of  a  pair  of  fine  dressing-forceps,  I  removed  a  bodkin,  which 
had  been  introduced  by  the  patient  for  the  purpose,  it  was  alleged,  of 
extracting  a  piece  of  gravel  from  the  urethra. 

A  case  was  narrated  by  Dr.  Grimsdale,  at  the  Liverpool  Medical 
Society,  in  1865,  where  he  had  removed  a  phosphatic  concretion, 
formed  on  a  large  hair-pin,  from  the  bladder  of  a  young  lady,  aged 
fifteen  years.  Removal  of  the  foreign  body  was  effected  with  forceps, 
after  rapidly  dilating  the  urethra  with  a  dilator.  On  the  second  day 
after  the  operation  she  was  able  to  pass  water  voluntarily ;  recovery 
followed,  the  patient  possessing  full  power  over  the  bladder.  In  this 
instance  there  was  some  tumefaction  above  and  to  the  left  side  of 
the  symphysis  pubis,  as  if  an  abscess  were  impending.  It  is  proba- 
ble that  the  foreign  body  might  have  been  expelled  in  this  way  had 
not  its  removal  been  effected  by  surgical  interference.  I  would  pre- 
fer, under  similar  circumstances,  supra-pubic  cystotomy  to  urethral 
dilatation.  Hair-pins  appear  to  be  rather  favorite  articles  for  pass- 
ing into  the  female  bladder,  as  many  cases  are  recorded. 

Foreign  bodies  in  the  rectum  sometimes  excite  considerable  irrita- 
tion in  the  bladder.  In  an  instance  that  came  under  my  notice  the 
lodgment  of  a  fishbone  in  the  bowel,  just  within  reach  of  the  finger, 
kept  up  intense  vesical  irritability,  which  disappeared  on  the  removal 
of  the  cause.  In  another  case  the  retention  of  a  small  gold-plate,  with 
a  false  tooth,  produced  similar  effects.  Scybala  and  hardened  faeces 
may  act  in  the  same  way,  especially  when  the  prostate  is  large  and 
presses  on  the  bowel.  Washing  out  the  rectum  thoroughly  every 
morning  with  a  copious  enema  often  proves  of  the  greatest  comfort  in 
the  latter  class  of  cases. 

INFLAMMATION   OF    THE  BLADDER. 

Cystitis,  or  inflammation  of  the  bladder,  is  an  affection  of  fre- 
quent occurrence.  It  is  a  disorder  which  often  requires  some  me- 
chanical management,  such  as  the  use  of  the  catheter  or  washing  out 
the  bladder;  and  therefore,  for  its  successful  treatment,  much  de- 
pends not  only  upon  the  manual  skill  of  the  practitioner,  but  also 
upon  his  judgment  in  the  selection  of  the  necessary  applications.  Cys- 
titis rarely  occurs  as  an  idiopathic  disorder,  but  commonly  in  associ- 
ation with  some  other  derangement  of  the  urinary  system.  Formerly 
it  was  seen  as  a  consequence  of  the  old  operation  of  lithotrity,  where, 
after  each  crushing,  rough  fragments  of  stone  were  left  in  the  bladder 
and  excited  inflammation.  This  comi)lication  often  proved  so  rapidly 
fatal  as   seriously  to  compromise  this  proceeding.     The  important 


224  HAEBISON — DISEASES  OF  THE  BLADDEE. 

improvement  introduced  by  Bigelow,  of  crusliing  and  removing  the 
fragments  of  stone  by  suction  at  tlie  same  time,  disposed  of  the  most 
frequent  cause  of  acute  cystitis  we  then  had  to  deal  with. 

Acute  cystitis  is  generally  traceable  to  injuries  involving  the  pelvis 
and  bladder,  to  the  introduction  of  foreign  bodies  or  septic  germs  of 
an  irritating  nature  into  the  bladder,  and  to  the  decomposition  of 
urine.  When  the  bladder  is  acutely  inflamed  we  have  all  the  local 
and  general  symptoms  more  or  less  prominent  of  an  active  inflamma- 
tion of  a  vital  organ.  There  is  supra-pubic  pain  and  tenderness, 
sometimes  running  into  general  peritonitis,  with  vesical  and  rectal 
tenesmus,  and  the  process  of  expelling  the  scanty  high-colored  urine 
is  extremely  distressing.  Sometimes  there  is  retention,  but  not  al- 
waj^s.  The  urine  is  often  remarkable  in  appearance,  resembling  thin 
prune  juice,  and  containing  blood  and  mucus  intimately  mixed  with 
it.  Under  the  acute  cystitis  of  prolonged  retention  of  decomposing 
urine,  both  in  men  and  women,  the  whole  mucous  coat  may  come 
away  entire,  or  in  detachments  as  a  sloughy  mass. 

A  rapid  disorganization  of  the  bladder  is  sometimes  observed  in 
association  with  disease  of  the  spinal  cord,  and  is  probably  depen- 
dent, as  Charcot "  suggests,  upon  irritation  of  certain  parts  of  the 
latter,  and  more  particularly  of  the  gray  matter.  This  is  exemplified 
in  the  following  case : 

Case. — T.  R.,  aged  21,  a  porter,  had  previous  to  his  present  ill- 
ness enjoj' ed  good  health.  There  was  no  history  of  syphilis.  Two 
days  before  his  admission  to  the  Liverpool  Infirmary,  when  at  work, 
he  was  seized  with  pain  in  the  bowels.  He  walked  home,  took  a  dose 
of  castor-oil,  and  applied  a  mustard  poultice  to  the  abdomen.  In  the 
night  he  tried  to  get  up,  and  found  that  one  leg  was  useless  and 
numb.  In  the  morning  both  legs  were  numb  and  absolutely  power- 
less, and  he  was  unable  to  pass  his  water.  When  brought  to  the 
hospital  it  was  found  that  there  was  complete  loss  of  power  and  sen- 
sation in  the  lower  extremities.  The  urine  had  to  be  drawn  off,  and 
was  found  to  contain  pus  and  mucus.  It  was  alkaline,  and  in  the 
course  of  two  or  three  days  large  quantities  of  blood  were  found  mixed 
with  it.  Extensive  sloughing  of  the  bladder  followed,  and  for  some 
time  before  death  all  the  urine  was  passed  by  the  rectum.  On  post- 
mortem examination  the  spinal  cord  in  the  lower  dorsal  region  was 
found  softened.  On  section  the  distinction  between  gray  and  white 
matter  was  ill-defined.  Under  the  microscope  the  large  cells  in  the 
gray  matter  were  much  altered  in  shape,  and  dilated  vessels  and 
leucocytes  were  observed  in  large  numbers.  The  coat  of  the  bladder 
had  sloughed,  and  abscesses  had  formed  around  it,  thrgugh  one  of 
which  a  communication  was  estabhshed  with  the  rectum. 

It  seems  hardly  possible,  as  Charcot  urges,  that  such  acute 
changes  as  these  could  be  induced  by  the  mere  contact  of  urine,  how- 


INFLAMMATION  OF  THE  BLADDER.  225 

ever  decomposed,  or  by  the  introduction  from  without  of  any  septic 
material  by  catheters.  The  rapidity  of  the  symptoms,  in  the  few  in- 
stances of  this  condition  which  I  have  seen,  rendered  all  local  treat- 
ment beyond  the  use  of  the  catheter  practically  useless. 

In  the  treatment  of  acute  cystitis  we  shall  do  well,  in  the  absence 
of  obvious  causes  of  inflammation,  as  injuries  and  such  like,  to  have 
regard  to  the  possibility  of  a  foreign  bod}^  having  been  introduced 
into  the  bladder.  In  a  most  acute  case  of  this  kind  it  turned  out  that 
the  patient  had  passed  a  grass-head  into  the  bladder,  the  stalk  of 
which  had  penetrated  the  fundus  of  the  viscus,  and  made  its  way,  to- 
gether with  the  urine,  into  the  abdomen  (Fig.  34) .  If  there  is  a  cause 
for  the  cystitis  that  can  be  removed,  as  for  instance  a  stone  frag- 
ment, this  wiU  be  the  first  indication  to  fulfil.  For  relief,  reliance 
will  chiefly  be  placed  in  warm  soothing  applications  about  the  part, 
with  anodynes,  either  local  or  general.  A  few  leeches  applied  to  the 
perinseum  generally  remove  the  feeling  of  tension  about  the  neck  of 
the  bladder  which  is  often  complained  of.  Demulcent  drinks  and 
febrifuges  are  also  useful.  I  do  not  know  anything  which  oftener 
gives  relief  than  introducing  a  soft  rubber  catheter,  and  running  into 
the  bladder  just  as  much  warm  water  as  can  be  tolerated  with  com- 
fort. This  may  be  done  frequently,  and  is  always  grateful  to  the 
patient. 

I  will  now  notice  those  forms  of  cystitis  of  commoner  occurrence 
which  we  meet  with  as  complications  of  other  urinary  disorders.  We 
shall  recognize  the  following  circumstances  under  which  they  happen : 

1.  As  produced  by  the  extension  of  inflammation  from  some  other 
part,  as  in  gonorrhoea ;  this  may  be  called  metastatic  cystitis. 

2.  As  a  consequence  of  obstructed  micturition,  as  in  stricture, 
or  hypertrophy  of  the  prostate — the  cystitis  of  obstruction. 

3.  As  caused  by  an  irritant  in  the  bladder,  such  as  a  calculus  or 
a  growth — the  cystitis  of  direct  irritation. 

1.  Metastatic  Cystitis. — It  is  not  uncommon  to  find  cystitis, 
in  various  degrees,  occurring  as  a  consequence  of  gonorrhoeal 
urethritis,  and,  like  other  metastatic  inflammations,  the  primary 
disorder  often  abates  as  the  change  in  locality  takes  place.  In  the 
slighter  forms  of  cystitis  resulting  from  gonorrhoea,  or  those  pro- 
voked by  such  causes  as  exposure  to  cold,  we  have  this  condition 
indicated  by  a  frequent  discharge  of  urine  more  or  less  loaded 
with  mucus.  In  the  severer  forms,  in  addition  to  constitutional 
fever,  the  bladder  is  intolerant  of  the  presence  of  urine  within  it, 
as  indicated  by  frequency  of  micturition,  and  tenesmus  produced 
by  the   contractile  power  necessary  to  expel.     The   urine  becomes 

purulent,  and  a  discharge  of  blood  not  infrequently  terminates  the 
Vol.  I.— 15 


226  HAERISON — DISEASES   OF  THE   BLADDEE. 

act  of  its  expulsion.  I  have  observed  the  greater  liability  to  cystitis 
and  bladder  irritation,  as  a  complication  of  gonorrhoea,  at  seasons  of 
the  year  when  sudden  changes  in  temperature  are  apt  to  occur. 
Hence  the  importance  of  providing  against  this  by  suitable  clothing 
and  by  avoiding  exposure  to  keen  winds. 

The  treatment  of  this  kind  of  cystitis  must  be  in  correspondence 
with  the  degree  of  inflammatory  action  that  is  taking  place.  In  the 
milder  forms,  where  irritation  best  describes  the  extent  to  which  the 
bladder  is  implicated,  the  suspension  of  any  kind  of  abortive  local 
treatment,  so  far  as  the  gonorrhoeal  discharge  is  concerned,  is  neces- 
sary. Rest,  in  the  recumbent  position,  and  soothing  applications,  in 
the  form  of  hot  opiate  fomentations  and  sedative  suppositories,  must 
be  substituted.  Of  the  demulcents  I  have  been  in  the  habit  of  pre- 
scribing, I  find  the  decoction  of  the  ulmus  fulva  or  slippery  elm,  in 
combination  with  the  succus  hyoscyami,  affords  the  speediest  relief. 
In  cases  of  gonorrhoeal  cystitis,  where  the  disorder  has  a  tendency 
to  become  chronic,  frequency  in  micturition  and  purulent  urine  re- 
maining after  the  more  acute  symptoms  have  subsided,  benefit  will 
be  found  from  the  use  of  copaiba,  or  the  oil  of  yellow  sandalwood ; 
these  remedies  are,  however,  not  well  borne  where  there  is  general 
febrile  disturbance. 

When  there  is  evidence  from  the  symptoms  and  the  presence  of 
gonorrhoeal  bacteria  that  the  bladder  is  similarly  affected  with  the 
urethra  as  a  consequence  of  the  specific  inflammation,  local  treatment 
is  generally  required  in  addition  to  the  sterilization  of  the  urine  from 
within  by  such  bactericides  as  quinine  or  boracic  acid.  This  is  best 
done  by  passing  a  small  rubber  catheter  well  anointed  with  carbolized 
vaseline  into  the  bladder  and  then  moderately  distending  it  with  half 
a  pint  or  so  of  some  disinfectant.  The  catheter  is  then  withdrawn 
and  the  patient  spontaneously  expels  the  contained  fluid.  In  this 
way  not  only  is  the  mucous  membrane  acted  upon  but  the  urethra  is 
flushed  in  the  most  thorough  manner.  This  process  should  be  car- 
ried out  once  or  twice  in  the  twenty -four  hours.  By  this  means  the 
urine  will  soon  present  a  normal  appearance.  Where  there  has  been 
a  chronic  infective  gleet  this  will  often  also  permanently  disappear 
under  this  process  of  irrigation.  I  usually  prefer  nitrate  of  silver  in 
the  proportion,  to  commence  with,  of  two  grains  to  the  pint  of  warm 
distilled  water,  the  strength  of  the  solution  being  gradually  increased 
until  half  a  grain  to  the  ounce  of  water  is  reached.  Neutral  sulphate 
of  quinine,  one  grain  to  the  ounce  of  water,  is  also  very  efficacious. 
Bichloride  of  mercury,  1  in  20,000,  may  also  be  used  as  an  efficient 
bactericide,  but  even  in  these  proportions  it  is  apt  to  cause  pain  and 
subsequent  irritation. 


INFLAMMATION  OF  THE  BLADDEK.  227 

2.  Cystitis  of  Obstruction. — Passing  to  the  cystitis  of  obstruction, 
we  shall  find  that  this  presents  itself  to  our  notice  as  chronic  and 
sub-acute.  The  chronic  form  is  usually  seen  in  cases  of  enlarged 
prostate  and  in  some  of  the  commoner  varieties  of  organic  urethral 
stricture.  The  cystitis  of  the  enlarged  prostate  is  due,  not  alone 
to  some  urine  remaining  in  the  bladder,  but  also  to  the  direct 
irritation  produced  by  protruding  masses  of  the  hypertrophying 
part.  This  irritation  leads  to  an  excess  of  mucus  being  thrown 
out,  and  its  accumulation  with  a  residuum  of  urine  in  the  most 
dependent  portion  of  the  viscus.  The  result  of  this  is  decompo- 
sition of  the  urine  and  the  evolution  of  ammonia.  By  the 
constant  presence  of  such  compounds  the  bladder  becomes  in- 
flamed, intolerant  of  its  contents,  liable  to  slight  hemorrhages,  and 
incapable  of  performing  its  natural  function  with  any  comfort  to  the 
patient.  Going  a  stage  further  on,  the  dilated  ureters,  and  perhaps 
the  pelves  of  the  kidneys,  share  in  these  changes,  and  thus  serious 
complications  are  almost  imperceptibly  added.  In  certain  cases  of 
stricture  much  the  same  sort  of  thing  occurs,  though  for  obvious  rea- 
sons the  amount  of  the  vesical  mucus  is  not  so  great  as  in  the  former 
illustration;  still  it  is  suflicient  to  produce  similar  changes  in  the 
urine.  This  excretion  is  rendered  alkaline  and  ammoniacal,  the  blad- 
der becomes  irritable,  the  patient  is  constantly  straining  to  emit  a  few 
drops  of  urine,  and  in  like  manner  with  the  cystitis  of  the  large  pros- 
tate, the  ureters  and  kidneys  may  eventually  become  involved. 

The  indications  for  treatment  are  tolerably  clear.  Remove  the 
cause  and  the  consequences  will  subside,  either  spontaneously  or 
with  the  assistance  that  art  can  render.  In  the  case  of  the  large  pros- 
tate this  cannot  always  be  done  to  the  extent  we  could  desire,  at  all 
events  in  many  of  those  instances  where  the  growth  has  been  of  a 
steadily  progressive  character.  The  obstruction,  if  it  cannot  be  re- 
moved by  operation,  may  be  largely  remedied  by  the  judicious  use  of 
the  catheter.  How  and  when  the  catheter  is  to  be  used  must  to  a 
large  extent  be  left  to  individual  experience  and  discretion.  Where 
cystitis  is  due  to  chronic  organic  stricture,  it  will  be  found  to  decline 
spontaneously  as  the  obstruction  yields  to  appropriate  treatment. 
Week  by  week,  as  dilatation  proceeds,  the  bladder  loses  its  irritability, 
and  the  alkaline  urine,  perhaps  ammoniacal  and  charged  with  mucus, 
resumes  its  normal  reaction  and  appearance.  The  next  indication  is 
to  prevent  the  contents  of  the  bladder  keeping  up  or  adding  to  the  in- 
flammation which  has  already  commenced.  Offensive  urine  and  tena- 
cious alkaline  mucus  arc  in  themselves  sufficient  elements  for  the  pro- 
duction of  inflammation  irrespective  of  the  obstruction  in  the  canal. 
To  correct  this,  and  to  remove  excess  of  mucus,  the  bladder  may  re- 


HABRISON — DISEASES  OF  THE  BLADDER. 

quire  ablution,  just  as  tlie  nasal  passages  do  when  they  are  the  seat  of 
offensive  ozsena.  These  details  will  be  referred  to  when  I  come  to 
speak  of  the  process  of  washing  out  the  bladder. 

The  acute  cystitis  of  obstruction  is  a  serious  form  of  the  disorder 
which  is  also  seen  in  connection  with  stricture  of  the  urethra  and 
prostatic  enlargement.  These  cases  generally  present  themselves  to 
our  notice  in  the  following  way :  We  are  called  to  see  a  patient  who 
has  been  suffering  from  stricture  for  some  years ;  the  difficulty  has 
gone  on  increasing,  the  urine  has  become  ammoniacal,  and  his  rest  is 
hourly  disturbed  to  pass  water,  which  he  does  in  small  drops  after 
much  straining.  Broken  down  with  all  these  symptoms  he  becomes 
feverish,  his  tongue  is  brown,  and  he  exhales  a  sickly  sort  of  ammo- 
niacal odor.  In  addition,  his  temperature  is  high,  pulse  rapid  and 
feeble,  and  he  may  have  had  a  rigor  followed  by  i^erspiration.  Prob- 
ably with  difficulty,  a  smaU  catheter  is  passed,  and  some  highly  fetid 
urine  escapes.  Both  the  general  and  local  state  indicate  a  condition 
of  acute  cystitis  with  inflamed  or  surgical  kidne5^  I  have  seen  a 
good  many  cases  of  this  kind,  and  about  their  treatment  no  doubt 
whatever  can  be  entertained.  The  position  is  this :  The  patient  can- 
not wait  to  derive  the  benefit  of  dilatation.  No  operation  for  the 
stricture,  such  as  internal  urethrotomy  or  a  divulsion,  is  to  be  recom- 
mended, as  the  sufferer  would  be  almost  sure  in  his  condition  to  die 
acutely  pysemic.  The  ovUj  way  of  dealing  with  him  under  these  cir- 
cumstances is  to  regard  his  bladder  in  the  light  of  an  acute  fetid  ab- 
scess recxuiring  an  opening  at  its  most  dependent  point.  It  would 
be  just  about  as  rational  to  propose  to  treat  a  fetid  ischio-rectal  ab- 
scess that  w^as  poisoning  a  man  acutely,  by  putting  a  trocar  into  it, 
as  to  think  of  relieving  a  septic  supjjurating  bladder  from  obstruction 
with  a  catheter  only.  A  grooved  staff,  or,  failing  this,  anything  to 
indicate  to  the  finger  the  line  of  the  urethra,  should  be  passed,  and  a 
perineal  opening  made  into  the  membranous  urethra  of  a  size  to  admit 
a  large  drainage-tube.  The  urine  should  not  all  be  removed,  if  the 
catheter  is  fii'st  introduced,  as  it  is  as  well  to  leave  sufficient  behind  to 
fuUy  realize  the  effect  of  the  incision  that  is  made.  The  bladder 
should  then  be  washed  out  and  allowed  to  drain  through  the  opening. 
In  cases  of  the  kind  to  which  I  am  now  referring,  where  this  course 
is  promptly  taken,  I  have  seen  patients  pass  as  it  were  in  a  few  hours 
from  approaching  death  to  rapid  convalescence.  By  this  treatment  I 
have  here  and  there  lost  a  dying  patient,  but,  on  the  other  hand,  I 
know  that  I  have  saved  many  more  who  would  otherwise  have  died. 
The  opening  gives  immediate  relief,  and  if  it  is  made  to  correspond  in 
size  with  the  drainage-tube  to  follow,  there  is  really  no  bleeding  or 
further  trouble. 


INFLAMMATION  OF  THE  BLADDER.  229 

In  the  treatment  of  less  urgent  forms  of  cystitis,  reference  is  often 
made  to  the  reaction  of  the  urine  as  indicating  the  necessity  for  ad- 
ministering either  acids  or  alkalies.  Our  object  should  be  to  obtain 
that  condition  of  the  excretion  which  most  nearly  corresponds  with 
its  normal  state,  as  we  sometimes  find  that  alkalies  are  poured  in  with 
a  vigorous  hand  and  regardless  of  the  fact  that  healthy  urine  has  an 
acid  reaction.  Still  we  must  not  forget  that  a  highly  acid  condition 
of  the  urine  is  often  intensely  irritating  to  the  inflamed  mucous  mem- 
brane with  which  it  comes  in  contact.  Sir  George  Johnson  has  shown 
the  value  of  milk  in  some  chronic  cases  of  cystitis,  and  of  skimmed 
milk  in  others.  The  pharmacopoeia  contains  a  number  of  drugs  which 
seem  to  exercise  a  soothing  or  anodyne  action  upon  the  mucous  mem- 
brane of  the  bladder  and  urinary  organs  generally ;  of  these  I  would 
mention  pareira  brava,  uva  ursi,  and  buchu.  Amongst  the  best  de- 
mulcents are  well-made  barley-water,  the  ulmus  fulva  or  slippery  elm, 
and  the  triticum  repens.  Belladonna  and  hyoscyamus  are  often  ex- 
tremely useful  in  allaying  the  irritability  of  the  bladder  associated 
with  cystitis.  There  is  a  combination  of  the  infusions  of  uva  ursi 
and  hops,  with  a  little  carbonate  of  soda  added,  the  use  of  which  will 
be  often  of  value  in  these  cases.  Of  other  drugs  I  have  found  ser- 
viceable in  varying  degrees  and  kinds  of  chronic  cystitis,  I  may  here 
mention  hyposulphite  of  soda  in  half-drachm  doses;  its  virtue  in 
purulent  urine  is  sometimes  remarkable.  Salol,  the  syrup  of  tar,  saw 
palmetto,  salicylate  of  soda,  pichi,  and  the  fluid  extract  of  the  Collin- 
sonia  canadensis  have  also  proved  themselves  of  service. 

Among  fruits,  the  common  blackberry  appears  to  exercise  a 
sedative  effect  on  the  mucous  membrane  of  the  urinary  passages.  My 
attention  was  first  directed  to  this  by  two  old  practitioners  who  were 
in  the  habit  of  prescribing  it  in  cases  of  chronic  cystitis.  I  have 
often  found  blackberry -tea,  prepared  from  the  jelly,  an  efficient  and 
not  a  disagreeable  demulcent  in  these  cases.  There  are  other  fruits 
and  vegetables  which  will  occasionally  be  found  useful.  For  instance 
a  distinguished  member  of  our  profession  writes  me :  "  It  is  a  curious 
thing  that  when  I  eat  gooseberries,  not  only  is  the  urine  increased  in 
quantity  but  it  is  always  clear  and  free  from  mucous  deposit,  and 
normally  acid."  The  ordinary  table  celery,  well  boiled,  is  often  ser- 
viceable as  ijart  of  the  diet  of  persons  liable  to  cystitis.  I  have,  on 
the  other  hand,  met  with  an  instance  where  the  eating  of  much  aspar- 
agus invariably  caused  ha3maturia.  An  excess  of  mucus  in  the  urine 
may  sometimes  be  corrected  by  ten  minims  of  terebene  in  a  capsule 
three  times  a  day,  and  the  same  may  be  said  of  a  combination  of  the 
oils  of  eucalyy)tus  and  of  cu})ebs.  In  the  treatment  of  chronic  inflam- 
matory affections  of  the  bladder  many  of  the  balsams  and  terebin- 


230  HARRISON — DISEASES  OF  THE  BLADDER. 

thinates  may  be  recommended.  The  use  of  saccharin  has  been  also 
advocated  for  this  purpose  by  Dr.  Little "'  of  Dublin. 

Opium  must  not  be  used  indiscriminately.  To  give  a  few  hours' 
repose  in  this  way  to  a  patient  who  really  requires  his  urine  drawn 
off  and  the  bladder  washed  out  is,  on  the  face  of  it,  not  good  prac- 
tice ;  though  when  such  points  have  been  attended  to,  it  is  often  in- 
valuable in  removing  the  extreme  sensitiveness  of  the  parts  which  is 
due  to  the  disease.  The  constipation  that  follows  the  use  of  this 
drug  in  chronic  sufferers  from  cystitis  negatives  the  good  otherwise 
gained  by  the  sleep  and  repose  that  are  obtained.  The  addition  of 
belladonna  to  the  opium  sometimes  removes  the  constipating  effect 
of  the  latter.  I  cannot  say  that  the  bromides  are  of  much  service  in 
this  class  of  cases,  unless  the  trouble  arises  more  from  nervous  than 
from  physical  causes.  Some  persons'  annoyances  seem  invariably 
to  gravitate  toward  their  large  prostates. 

Though,  as  a  rule,  retained  and  decomposing  urine  is  the  cause  of 
the  offensive  smell  sometimes  noticed  in  these  cases,  still,  in  spite  of 
catheterism  and  irrigation,  a  disagreeable  odor  may  remain.  Under 
these  circumstances,  the  administration  of  naphthalin  in  a  pill,  con- 
taining two  or  three  grains,  enclosed  in  a  gelatin  cachet,  will  be 
found  useful.  If  given  three  or  four  times  a  day  the  odor  of  the  drug 
will  be  found  to  overcome  the  disagreeable  one  the  urine  generates. 
Benzoic  and  boric  acid,  benzoate  of  ammonia  and  chlorate  of  pot- 
ash, administered  internally,  are  also  of  service  where  the  urine  un- 
dergoes change  of  this  kind.  It  is  by  sterilizing  the  urine  that  med- 
icines of  this  character  do  good. 

To  alleviate  the  extreme  irritability  of  the  bladder  which  often 
remains  after  the  more  active  symptoms  of  inflammation  have  passed 
away,  a  solution  of  morphine,  injected  into  the  bladder  with  a  gum- 
elastic  catheter  to  which  a  ball  syringe  is  attached,  often  gives  the 
patient  a  good  night  after  rectal  suppositories  in  various  forms  have 
been  tried. 

For  a  similar  object,  I  sometimes  employ  vesical  suppositories, 
containing  morphine,  belladonna,  bismuth,  and  other  soothing  agents. 
I  put  these  into  the  bladder  by  means  of  a  suppository-catheter,  made 
for  me  by  Messrs.  Krohne  and  Sesemann,  of  London.  The  instru- 
ment consists  of  a  silver  catheter,  open  at  the  end,  in  which  the  sup- 
pository is  placed.  By  means  of  this  instrument  the  whole  of  the 
urine  is  first  drawn  off,  after  which,  by  pressing  the  stylet,  the  sup- 
pository is  projected  into  the  bladder.  They  are  made  of  the  oleum 
theobromse,  and  are  so  shaped  as  to  fit  in  the  open  end  of  the  catheter, 
thus  giving  it  the  appearance  of  an  ordinary  instrument,  and  facili- 
tating its  passage  into  the  bladder.     The  shape  of  the  suppository  is 


INFLAMMATION  OF  THE   BLADDER.  231 

shown  in  the  sketch  (Fig.  40,  A) ;  they  contain  various  medicinal  ap- 
plications. A  grain  of  morphine,  introduced  into  the  bladder  in  this 
way,  and  repeated  twice  in  twenty-four  hours,  has  completely  relieved 
distressing  symptoms  of  irritation.  I  have  extended  the  application 
of  drugs  in  this  shape  to  other  cases  where  astringents  are  indicated. 


Fig.  40.— Vesical  Suppository  Catheter.    A,  Suppository. 

A  member  of  our  profession  writes  me :  "  I  have  received  more  benefit 
from  the  suppositories  of  cantharides  than  from  all  the  remedies  I 
have  tried  during  the  twelve  years  I  have  suffered  from  retention." 

Dr.  Dennis,  of  New  York,  thus  refers  ^°  to  this  method  of  medi- 
cating the  bladder  in  a  case  of  hemorrhagic  cystitis  complicating 
typhoid  fever :  "  After  the  bladder  had  been  washed  out  with  the  an- 
tiseptic solution,  iodoform  suppositories  were  introduced  into  the 
bladder  by  an  instrument  invented  by  Mr.  Reginald  Harrison.  The 
antiseptic  solution  cleansed  the  bladder,  and  the  iodoform  supposi- 
tories disinfected  the  residual  urine.  It  was  a  remarkable  clinical 
fact,  that  eleven  days  after  the  discontinuance  of  the  suppositories 
the  odor  of  the  iodoform  was  present  in  the  urine." 

There  are  causes  of  cystitis  other  than  those  I  have  previously 
enumerated  as  the  commoner  ones.  A  paralyzed  bladder,  as  we 
see  in  disease  and  injury  of  the  spinal  cord,  is,  sooner  or  later,  al- 
most sure  to  become  an  inflamed  one  in  the  way  that  has  already  been 
explained.  Catheterism  and  washing  out  the  bladder  will  do  much 
toward  mitigating  the  distress  of  these  patients  and  averting  a  fatal 
issue ;  for,  where  recovery  has  followed,  much  of  the  success  was  due 
to  the  absence  of  inflammation  of  the  bladder.  In  employing  cathe- 
terism in  these  cases,  we  ought  not  to  forget  that,  owing  to  the  absence 
of  sensibility  in  the  parts,  much  damage  may  be  inflicted  by  an  in- 
Judicious  employment  of  instruments,  without  the  patient  expressing 
that  consciousness  of  pain  which  otherwise  he  would  do.  The  great- 
est care  should  consequently  be  exercised  in  drawing  off  the  urine  to 
avoid  any  lesion  of  the  urethra  or  bladder,  which,  considering  the 
state  of  the  urine,  would  be  sure  to  provoke  further  complications. 
Almost  the  whole  comfort  of  the  patient  suffering  from  fracture  of 
the  sjnne  dei)ends  upon  the  manner  in  which  his  urinary  symptoms 
are  anticipated  and  managed.  Perineal  cystotomy  with  tube-drain- 
age has  ])ox)j\  practised  in  these  cases  by  Mr.  D.  Harrisson,  with  the  ob- 


232  HAERISON — DISEASES  OF  THE   BLADDER. 

ject  of  dispensing  witli  catlieterism  altogether,  but  I  liave  no  experience 
of  it  myself  under  these  circumstances.  Mr.  Wallis"  also  records  an 
instance  wliere  perineal  cystotomy  and  drainage  was  practised,  witli 
temporary  advantage,  in  a  patient  with  fractured  spine  who  was  dy- 
ing from  cystitis.  The  use  of  the  catheter  was  thus  rendered  unnec- 
essary. I  can,  however,  indorse  the  remark  made  by  the  late  Dr. 
Hilton  Fagge,  that  the  tendency  of  urine  in  paraplegia  to  putrefac- 
tion may  be  checked  by  the  administration  of  salicylic  acid  by  the 
mouth.  There  are  cases  of  chronic  cystitis  in  the  male  where  the  ex- 
pediency of  performing  cystotomy  and  of  draining  through  the  peri- 
naeum  may  with  much  propriety  be  considered  for  the  purpose  of 
giving  the  bladder  a  complete  rest,  both  from  the  operation  of  cathe- 
terism  as  well  as  from  its  own  irritable  contractions  or  spasms.  In 
some  instances,  where  all  other  means  have  been  tried  and  failed, 
very  satisfactory  results  have  been  obtained,  that  is  to  say,  the-  pa- 
tients have  derived  permanent  advantage.  The  details  of  this  pro- 
ceeding will  be  discussed  in  connection  with  the  operation  of  perineal 
puncture  and  drainage. 

Atony  of  the  bladder  is  often  seen  in  connection  with  cystitis. 
When  occurring  suddenly,  the  question  sometimes  arises.  Should  a 
catheter  be  permanently  retained  in  the  bladder?  My  opinion  corre- 
sponds with  the  following  remark  hj  the  late  Mr.  W.  Hey,  of  Leeds : 
"  I  feel  sure  that  a  patient  sooner  regains  the  power  of  emptying  his 
bladder  spontaneously  when  the  catheter  is  withdrawn  after  each  time 
it  is  used  than  when  it  is  retained."  Temporary  atony  is  sometimes 
seen  following  pressure  from  over-retention  of  urine,  just  as  the  arm 
may  be  temporarily  paralyzed  by  lying  on  it.  To  prevent  atony  be- 
coming permanent  much  may  be  done  by  the  mechanical  measures 
that  have  been  advocated.  In  addition,  medicines  such  as  iron,  nux 
vomica,  and  strychnine  have  proved  useful.  The  tincture  of  canthar- 
ides  is  an  old-fashioned  remedy,  which,  in  addition  to  its  diuretic 
properties,  probably  exercises  a  direct  stimulating  action  upon  the 
bladder  by  its  presence  in  the  urine.  Von  Langenbeck  has  found 
benefit  from  the  hypodermic  injection  of  ergotin. 

Care  must  be  taken  to  draw  a  distinction  between  the  inflamed 
bladder  that  is  either  entirely  or  partially  atonied  because  the  patient 
is  ataxic,  and  the  commoner  form  of  local  paralysis  to  which  refer- 
ence is  here  made.  Inflammatory  atony  is  not  unfrequently  seen  as 
a  remote  consequence  of  syphilis  in  middle-aged  men.  Here  both 
local  and  general  treatment  will  be  requisite.  Atony  with  cystitis, 
though  associated  with  urethral  stricture,  is  sometimes  due  to  a  cen- 
tral and  not  a  peripheral  cause ;  hence  it  is  well  not  to  promise  too 
much  even  after  the  stricture  has  been  disposed  of.     I  have  known/ 


INFLAMMATION  OF  THE  BLADDER.  ^Od 

the  bladder  treated  somewliat  actively,  witli  tlie  view  of  arousing  its 
supposed  dormant  action,  where  attention  should  also  have  been  de- 
voted to  the  state  of  the  nerve  centres,  which  was  the  primary  cause 
of  the  suspended  action  in  the  part. 

In  the  following  case  reference  is  made  to  the  tt-eatment  of  ataxia 
by  suspension,  so  far  as  the  bladder  symptoms  seemed  to  be  influenced 
by  the  process : 

Case. — A  male  patient,  aged  about  40,  came  under  my  care  early 
in  1890,  with  locomotor  ataxia  of  two  years'  duration.  He  had  diffi- 
culty in  commencing  to  pass  water,  which  was  increasing,  with  cys- 
titis and  ammoniacal  urine.  Under  Charcot's  advice  it  was  agreed 
that  suspension  should  be  tried  in  conjunction  with  the  administra- 
tion of  ergot.  I  completely  suspended  him  on  fourteen  occasions  in 
two  months,  from  sixty  to  ninety  seconds  at  a  time,  with  the  result 
that  the  bladder  symptoms  entirely  subsided,  and  the  patient  was  able 
to  resume  active  official  duties.  The  patient  had  no  stricture  and  no 
urethral  instrument  was  used. 

In  the  treatment  of  cystitis  as  it  occurs  in  females,  we  can  have 
no  better  instructions  than  those  contained  in  a  practical  paper  by 
Dr.  J.  Braxton  Hicks.  The  author  points  out  how  little  is  to  be  ex- 
pected from  internal  remedies,  beyond  correcting  abnormal  states  of 
the  urine  and  disordered  functions,  and  how  much  may  be  done  by 
local  treatment.  Eeliance  is  chiefly  placed  upon  washing  out  the 
bladder  with  slightly  acidulated  warm  water  until  it  is  clear  of  phos- 
phates and  mucus,  and  afterwards  injecting,  with  a  view  of  its  reten- 
tion, a  solution  of  morphine.  Subsequently  permanganate  or  chlorate 
of  potash  is  employed  in  a  similar  manner.  On  the  subsidence  of  the 
acuter  symptoms,  injections  of  tannin  or  of  perchloride  of  iron,  fol- 
lowed by  morphine,  are  substituted,  and  are  again  changed,  as  the 
bladder  becomes  less  sensitive,  for  more  potent  astringents,  such  as 
nitrate  of  silver.  "  The  benefit  of  such  management  is  very  marked  in 
cases  of  paralysis  where,  from  retention  or  the  rapid  ammoniacal  de- 
composition of  the  urine,  the  pain  and  constitutional  irritation  are 
very  distressing ;  and  thus  we  can  often  lessen  the  chance  of  the  exten- 
sion of  the  irritation  to  the  kidneys.  Again,  in  malignant  disease,  the 
simple  injection  of  acidulated  warm  water  gives  amazing  comfort,  re- 
moving the  phosphates  and  ammonia,  and  when  to  this  is  added  the 
morphia,  a  wonderful  comfort  is  felt.  Indeed,  so  much  relief  is  ob- 
tained that,  with  a  large  calculus  in  the  bladder,  its  presence  is  almost 
entirely  unfelt  if  morphia  be  daily  injected."  °" 

There  are  in  women  forms  of  chronic  cystitis  and  vesical  irritability 
of  a  very  obstinate  nature  where  it  is  difficult  to  detect  any  structural 
alterations.  In  some  of  these  cases  Mr.  Teale '"  has  shown  that  great 
benefit  follows  tlui  induction  of  a  condition  of  transient  incontinence 


284  HAKEISON — DISEASES  OF  THE  BLADDER. 

of  urine  by  over-dilatation  of  tlie  uretlira.  This  is  a  mode  of  resting 
tlie  bladder  which,  like  others  where  a  temporary  vesico-vaginal  fistula 
is  established  by  incision,  may  with  advantage  be  employed  in  obsti- 
nate cases  of  the  kind  referred  to.  For  the  sympathetic  or  local  irrita- 
tion alone,  which  so  frequently  attends  urinary  tuberculosis,  I  have  not 
met  with  such  results  in  my  own  experience  as  would  make  me  com- 
mend this  principle  of  proceeding.  The  reflex  irritation  of  urinary 
phthisis  is  best  met  by  anodynes. 

In  all  cases  of  chronic  cystitis  whatever  may  be  the  cause,  the 
practitioner  should  be  alive  to  the  possibility  of  a  phosphatic  stone 
forming.  These  concretions  sometimes  accumulate  with  great  rapid- 
ity, and  when  detected  are  apt  to  lead  the  patient  or  his  friends  to 
suspect  that  the  stone,  which  perhaps  some  one  else  detected,  was  the 
cause  and  not  the  consequence  of  the  disorder  undergoing  treatment. 
I  have  on  several  occasions  known  phosphatic  stones,  of,  say,  an  inch 
in  diameter,  form  in  a  few  weeks. 

By  the  kindness  of  my  colleague  Mr.  Heycock,  I  had  the  oppor- 
tunity of  seeing,  in  his  practice  at  St.  Peter's  Hospital,  a  case  of 
much  interest  and  importance.  It  was  one  of  acute  cystitis  in  a  man 
of  about  40,  with  a  urethral  stricture  of  some  standing,  where  the  en- 
tire mucous  membrane  of  the  bladder  exfoliated  and  was  withdrawn 
in  the  form  of  a  loose  bag  through  a  perineal  cystotomy.  The  latter 
was  rendered  necessary  by  the  fetid  character  of  the  urine  and  the 
recurrence  of  retention  from  impaction  of  the  detached  membrane  in 
the  outlet  from  the  bladder.  A  drainage-tube  was  placed  in  the  blad- 
der through  the  wound.  Immediate  relief  followed  the  operation,  and 
the  patient  rapidly  progressed  toward  recovery.  The  mucous  coat 
had  a  granular  appearance,  and  was  much  roughened  by  the  deposi- 
tion of  phosphates  upon  it. 

These  cases  are,  it  is  hardly  necessary  to  state,  widely  different 
from  others  where  a  false  lining  or  membrane  appears  to  form  within 
the  bladder,  and  keeps  up  a  cystitis.  Dr.  Cabot,  of  Boston,  U.  S.  A.,'" 
reports  such  a  case,  under  the  name  of  pacchydermia  vesicae,  where, 
on  opening  the  bladder  above  the  pubes  to  relieve  urgent  symptoms 
it  was  found  "  that  a  thick  membrane  could  be  detached  from  the  dis- 
eased surface,  and  with  care  could  be  peeled  off  with  the  fingers  in 
sheets  of  one  or  two  square  inches  in  area.  It  was  loosely  attached, 
and  after  removal  left  a  smooth  surface  which  bled  but  slightly.  The 
wall  of  the  bladder  which  it  left  felt  soft  and  supple."  The  patient 
steadily  improved,  and  the  following  year  it  is  stated  he  was  able  to 
resume  hard  work.  Pathologically  the  membrane  is  described  as 
"  made  up  entirely  of  epithelium,  from  fifty  to  one  hundred  times  as 
thick  as  the  epithelial  layer  normally  existing  on  the  bladder  wall, 


IKPLAMMATION  OP  THE  BLADDER.  235 

and  its  nourisliment  was  provided  for  by  papillae  thrown  up  by  the 
connective  tissue  below."  Referring  to  treatment,  other  than  by 
operation,  it  is  observed  that  nitrate  of  silver  injections  seemed  to  an- 
swer in  allaying  inflammation.  Dr.  J.  P.  Bryson  suggested  that,  as 
he  had  had  excellent  results  in  the  treatment  of  chronic  cystitis  from 
injections  of  salicylic  acid,  this  drug  would  be  applicable  here,  as  it 
had  the  power  of  removing  warts,  corns,  and  other  growths  of  hyper- 
plastic epithelium.  Dr.  Cabot  expresses  his  acknowledgments  to  a 
paper  by  Posner,  upon  "Dermoid  Changes  in  Mucous  Membranes,"  ^' 
for  the  pathological  consideration  of  the  subject.  In  a  case  I  saw  re- 
cently, in  conjunction  with  Mr.  T.  P.  Teale,  a  very  similar  state  of 
things  was  found  on  opening  the  bladder  above  the  pubes.  Mr.  Teale 
thus  describes  it  in  a  letter  to  me :  "  The  condition  of  the  bladder  was 
such  as  I  never  experienced.  The  whole  of  the  mucous  membrane 
was  in  a  velvety  or  granular  condition,  and  was  almost  completely 
lined  by  a  membrane  (diphtheritic?)  like  soft  writing-paper.  This 
membraneous  material  seemed  gradually  to  disappear  in  the  course 
of  a  week  or  two.  I  had  a  good  view  of  the  neck  of  the  bladder 
through  a  small  Ferguson's  uterine  speculum.  It  was  fringed  by 
feathery  warts  or  elongated  papillae,  a  greater  part  of  which  I  removed 
by  forceps  and  scissors." 

The  question  has  arisen  in  practice  as  to  whether  a  person  suffer- 
ing from  chronic  cystitis  and  decomposing  urine  is  capable,  during  the 
continuance  of  these  symptoms,  of  procreating.  The  evidence  is 
against  the  possibility,  so  far  as  I  have  been  able  to  observe,  where 
the  urine  is  from  such  causes  loaded  with  bacteria. 

Toilet  of  the  Bladde7\ — After  the  general  consideration  of  cystitis, 
I  shall  now  refer  to  what  may  appropriately  be  called  the  toilet  of  the 
bladder.  This  will  include,  first,  the  mechanism,  and  then  the  ma- 
terials appropriate  to  each  class  of  case.  In  the  first  place,  it  is  well 
to  remember  that  the  j^rocess  of  washing  out  some  bladders  is  a  very 
different  thing  to  what  it  is  in  others.  This  will  readily  be  under- 
stood by  comparing  a  pouched  bladder  with  a  tolerably  normal  one. 
In  the  former  case,  unless  the  siphon-action  of  the  catheter  is  perfect, 
a  considerable  amount  of  urine,  perhaps  loaded  with  mucus  or  pus, 
may  be  left  behind  to  decompose  and  become  swarming  with  various 
kinds  of  bacteria.  Hence  the  catheter  should  be  gently  moved  about 
and  partially  withdrawn  as  the  flow  ceases,  to  see  if  another  collection 
of  urine  can  be  tapped.  As  I  have  elsewhere  stated,  in  some  instances 
it  is  even  well  to  let  the  patient  lie  over  on  his  side,  so  as  to  render 
the  abdomen  somewhat  dex)endent,  before  the  catheter  is  finally  with- 
drawn. It  can  be  understood  how  a  metal  catheter  may  positively 
shut  down  a  sort  of  i^rostatic  valve  by  its  weight,  and  render,  from  the 


236  HAHEISON — DISEASES  OF  THE  BLADDEB. 

position  of  the  exit  aperture,  tlie  complete  emptying  of  the  bladder  an 
impossibility. 

For  ordinary  purposes,  I  usually  employ  a  soft  silk  or  rubber 
catheter  with  a  bevelled  eye,  and  a  rubber  bottle  holding  four  or  six 
ounces  of  fluid,  with  a  brass  nozzle  and  stopcock,  which  can  easily  be 
screwed  on,  or,  what  is  better,  be  connected  by  means  of  a  bayonet  joint. 
The  nozzle  should  taper  to  a  fine  point  so  that  it  may  fit  catheters  of 
various  sizes.  I  formerly  used  double-current  metal  catheters,  but 
these  I  have  discarded,  for  the  reasons  that  an  unyielding  instrument 
is  not  so  generally  applicable  as  a  flexible  one,  and  because  there  is 
no  object  in  having  an  arrangement  for  the  sj-nchronous  flow  of  fluid 
into  and  out  of  the  bladder  at  the  expense  of  the  calibre  of  the  tube. 
The  soft  catheter  having  been  introduced,  and  the  rubber  bottle  filled 
and  connected  with  it,  the  fluid  is  gently  pressed  by  the  hand  on- 
ward to  the  bladder.  Two  or  three  ounces  usually  suffice  for  a  time, 
the  tap  is  again  turned  and  the  fluid  retained  in  the  bladder  for  a  few 
moments,  and  then  allowed  to  escape.  This  process  may  be  repeated 
two  or  three  times  until  the  return  fluid  indicates  that  the  object  in- 
tended has  been  attained.  The  process  should  be  a  painless  one,  with- 
out i)rovoking  either  bleeding  or  spasm.  Mr.  Buckston  Browne  ^°  has 
described  a  tube  which  can  be  fitted  to  almost  any  catheter,  by  which 
a  Higginson's  syringe  may  be  adapted  for  fiUing  the  bladder,  while 
by  raising  the  finger  from  over  one  of  the  openings,  the  current  is  re- 
versed and  the  fluid  ejected. 

I  used  to  wash  out  with  a  glass  funnel  to  which  about  two  feet  of 
rubber  tubing  and  a  catheter  were  fitted.  When  the  funnel  is  elevated 
and  water  poured  into  it,  the  latter,  by  hydrostatic  pressure  propor- 
tionate to  the  calibre  and  length  of  the  tubing,  flows  into  the  bladder, 
and,  upon  the  funnel  being  depressed  below  the  level  of  the  patient's 
pelvis,  escapes. 

Where  the  bladder  is  much  pouched  or  irregular  in  shape,  it  is 
better  to  employ  hydrostatic  pressure  in  the  form  of  a  reservoir  or 
rubber  bag  (which  is  convenient  for  travelling),  as  shown  in  Fig.  41, 
representing  an  arrangement  described  by  Dr.  Keyes.  By  this  plan 
the  bladder  can  be  very  gradually  filled,  so  as  to  float  out  of  these 
various  depressions  and  crevices  pieces  of  tenacious  mucus  which 
otherwise  would  remain  behind  and  keep  up  irritation  and  bacterial 
decomposition.  From  the  sketch  (Fig.  41)  it  will  be  seen  that  the 
apparatus  consists  of  a  rubber  bottle  (A)  capable  of  holding  a  pint  of 
fluid,  which  can  be  suspended  to  any  convenient  hook ;  a  piece  of  tub- 
ing (B),  five  feet  in  length,  terminating  in  a  stopcock  (C),  which  per- 
mits fluid  to  flow  either  through  the  catheter  end  (D)  or  the  outlet 
pipe  (E),  according  to  the  direction  in  which  the  tap  is  turned.     A 


INFLAMMATION  OF  THE  BLADDEE. 


237 


conical  metallic  catheter  mouthpiece  {F)  completes  the  connection 
with  the  catheter  {G).  A  soft-rubber  catheter  is  generally  preferred. 
The  instrument  is  used  in  the  following  way :  The  bag  or  reservoir, 
being  filled  with  the  fluid  to  be  injected,  is 
hung  up  about  six  feet  from  the  floor.  The 
stopcock  (0)  is  then  turned  until  some  of  the 
fluid  escapes,  so  that  no  air  is  allowed  to  enter 
the  bladder.  The  patient,  being  in  the  erect 
position,  then  introduces  the  catheter  and 
connects  it  with  the  tubing.  By  the  alternate 
action  of  the  tap  ((7)  the  fluid  is  made  either 
to  enter  the  bladder  or  to  escape ;  if  the  lat- 
ter, it  passes  into  the  receptacle  {H).     The 


Fig.  41.— Apparatus  for  Washing  out  the  Bladder.    For  explanation  of  letters,  see  text. 

instrument  can  be  adapted  to  the  recumbent  position,  and  also  ena- 
bles patients  to  perform  this  operation  readily  without  assistance. 

Care  should  be  taken  to  avoid  forcing  air  into  the  bladder  when 
the  urine  contains  blood  or  pus,  as  it  sometimes  leads  to  putrefac- 
tion and  the  evolution  of  gas,  which  may  cause  spasm.  As  the  blad- 
der is  expelling  the  last  portion  of  the  injection,  if  the  surgeon  is 
holding  the  catheter,  he  sometimes  feels  a  slight  click  or  concussion, 
which  the  patient  with  a  sensitive  bladder  is  conscious  of  and  would 
rather  avoid.  I  believe  it  is  caused  by  the  mucous  membrane  being 
drawn  into  the  eye  of  the  catheter  as  the  bladder  is  emptied  of  the 
last  few  drops.  It  is  prevented  by  watching  the  flow,  and  withdraw- 
ing the  catheter  until  the  end  is  well  within  the  prostate  as  the  last 
portion  of  fluid  escapes.  Catheters  for  this  purpose  should  have  the 
ox)ening  of  moderate  size,  with  the  edge  bevelled,  so  as  not  to  scratch 
the  urethra ;  to  avoid  more  of  the  catheter  being  introduced  into  the 
bladder  than  necessary,  the  opening  should  be  close  to  the  end  of  the 


238  HAERISON — DISEASES  OF  THE  BLADDEE. 

instrument.  When  using  rubber  bottles  for  washing  out  the  bladder 
care  should  be  taken  that  they  are  thoroughly  aseptic  and  not  struc- 
turally disqualified  by  age. 

We  have,  I  think,  been  disposed  to  make  this  excellent  practice 
of  irrigation  a  fashion  in  bladder  cases,  where,  though  there  may  be  a 
call  for  the  catheter,  the  ablution  following  may  prove  unnecessary. 
In  some  cases  of  partial  retention  where  the  catheter  is  required,  it 
must  not  be  forgotten  that  so  long  as  the  vesical  mucus  is  normal  in 
quantity  and  quality,  it  serves  a  purpose  in  protecting  a  surface, 
which,  by  reason  of  the  inequalities  of  the  bladder  arising  out  of  the 
enlargement  of  the  prostate,  has  no  means  of  completely  contracting 
or  covering  itself,  until  time  has  elapsed  for  the  excretion  of  the  re- 
quisite amount  of  residual  urine.  I  am  reminded  of  this  when  I  hear 
patients  complaining  of  irritability  of  the  bladder,  which  takes  a 
little  time  to  subside,  directly  after  they  have  been  washed  out. 

Washing  out  is  required  for  various  purposes,  most  commonly  for 
the  removal  of  mucus  or  muco-pus,  which  often  collects  in  the  depen- 
dent parts  of  the  bladder,  especially  where  the  prostate  is  large.  If 
left  to  accumulate,  this  viscid  secretion  excites  spasm  and  causes  am- 
moniacal  decomposition  of  the  urine,  thus  adding  considerably  to 
other  sources  of  irritation.  I  know  no  better  solvent  for  this  than 
common  salt,  in  the  proi^ortion  of  a  teaspoonful  or  so  to  a  pint  of 
tejjid  water,  for  use  with  an  irrigator.  In  connection  with  this 
remark  Dr.  Gouley  ''  has  pointed  out  that  bladders  which  have  long 
contained  purulent,  slimy  urine  do  not  bear  the  contact  of  limpid 
fluids  of  low  specific  gravity  well  at  first,  and  it  is  therefore  necessary 
in  some  instances  to  increase  artificially  the  density  of  the  water. 
Such  a  lotion  is  less  irritating  to  the  mucous  membrane  than  plain 
water,  as  we  recognize  in  the  treatment  of  ozsena.  In  other  instances, 
a  solution  of  boracic  acid  answers  better.  Very  hard  waters  should 
not  be  used  for  such  purposes.  It  is  just  as  easy  "  to  chap"  the  bladder 
in  this  way  as  the  hands.    Distilled  or  rain  water  may  be  siibstituted. 

The  next  class  of  cases  includes  those  where  the  contents  of  the 
bladder  are  rendered  offensive  by  decomposition.  We  know  how 
•disagreeable  the  urine  can  become  both  to  the  patient  and  to  the 
practitioner.  Carbolic  acid  will  be  found  an  appropriate  antiseptic, 
but  it  must  not  be  used  stronger  than  one  in  eighty,  otherwise,  if  it 
becomes  absorbed,  it  may  occasion  that  peculiar  condition  known  as 
carboluria.  Solutions  of  sanitas,  boro-glyceride,  and  sulpho-carbol- 
ate  of  soda  may  also  be  employed  for  the  same  purpose. '  Eesorcin, 
creolin,  and  nitrite  of  amyl  are  also  recommended  as  useful  disinfec- 
tants. When  the  urine  remains  purulent  after  cystitis  nothing  often 
succeeds  better  than  a  quinine  wash,  as  first  recommended  by  Mr. 


INFLAMMATION  OF  THE  BLADDER.  239 

Nunn,"  who  speaks  of  its  action  as  a  bactericide.  The  neutral  sul- 
phate should  be  used  in  the  proportion  of  one  grain  to  an  ounce  of 
distilled  water  to  commence  with,  and  if  the  solution  is  not  quite 
clear,  a  drop  of  dilute  muriatic  acid  may  be  added.  Some  of  the  in- 
jection may  be  left  in  the  bladder.  The  internal  administration  of 
quinine,  in  doses  of  five  grains,  not  only  acts  as  a  sedative  to  the 
bladder  after  cystitis,  but  is  useful  in  sterilizing  the  urine.  Its  effi- 
cacy for  this  purpose  has  been  urged  by  Dr.  Simmons,"  who,  in  ex- 
plaining the  nature  of  this  action,  refers  to  an  observation  by  Dr. 
Kerner,  that  seventy  per  cent,  of  the  drug  is  eliminated  by  the  kid- 
neys in  from  three  to  twenty-four  hours  after  it  has  been  taken. 
Quinine  is  employed  in  this  way  after  operations  on  the  urethra,  with 
the  best  results.  It  sometimes  happens  that  after  attacks  of  cystitis 
the  urine  remains  alkaline,  and  there  is  a  tendency  to  throw  down 
phosphates,  which  often  concrete  in  the  form  of  a  mortar-like  sub- 
stance. From  five  to  ten  grains  of  citric  acid  in  a  pint  of  warm,  water, 
used  as  an  injection,  will  often  correct  this  disposition,  which  is  prob- 
ably primarily  due  to  excess  of  vesical  mucus.  The  mineral  acids 
are  not  well  borne  locally. 

Sir  William  Koberts  ^°  has  suggested  that  the  lactic  fermentation 
may  be  made  use  of  as  a  counter-septic  agent  in  cases  of  ammoniacal 
decomposition  of  the  urine,  and  that  thus  the  formation  of  phosphatic 
concretions  may  be  prevented. 

I  have  availed  myself  of  this  suggestion  with  obvious  advantage 
in  some  cases  of  ammoniacal  urine  where  there  was  every  disposition 
to  form  stone.  For  this  purpose,  as  a  preliminary,  the  bladder 
should  be  washed  out  with  a  solution  of  citric  acid  in  the  proportion 
of  ten  grains  to  a  pint  of  tepid  water.  After  this  has  been  done,  an 
ounce  of  water  containing  a  drachm  of  malt  extract  (bynin)  is  injected 
into  the  bladder,  and  retained  there. 

The  mucous  membrane  sometimes  remains  sensitive  after  the 
acuter  symptoms  of  inflammation  have  subsided,  when  a  soothing  or 
anodyne  solution  will  be  serviceable.  For  this  purpose  a  solution  of 
borax  in  glycerin,  with  tepid  water  added,  makes  a  good  wash.  Sir 
Henry  Thompson's  formula  is  as  follows  ("Diseases  of  the  Urinary 
Organs")  :  Glycerin,  two  ounces ;  biborate  of  soda,  one  ounce ;  dis- 
solve, and  add  two  ounces  of  water ;  half  an  ounce  of  this  solution  to 
four  ounces  of  warm  water  is  a  suitable  proportion.  Some  of  the 
most  troublesome  cases  of  irritable  bladder,  arising  from  this  cause, 
yield  entirely  to  the  daily  use  of  a  solution  of  bismuth.  A  table- 
spoonful  of  the  lac  bismuthi  (Symes  &  Co.)  to  six  ounces  of  warm 
water  represents  an  ai)X)ropriate  strength.  As  a  local  application  I 
,  have  found  this  salt  as  useful  iu  bladder  affections  as  it  appears  to 


240  HAEEISON — DISEASES  OP  THE  BLADDER. 

be  in  otlier  disorders  of  tlie  mucous  tract,  wliere  it  acts  meclianically 
in  protecting  or  coating  over  tlie  irritable  membrane.  Other  cases  of 
this  kind  yield  to  irrigation  of  tlie  bladder  witb  tolerably  bot  water. 
We  may  commence  witb  it  at  98°  Eahr.,  and  gradually  increase  the 
temperature  to  115°  or  120°  Fahr. 

In  tubercular  ulceration  of  the  bladder  no  application  is  so  useful 
as  a  wash  of  corrosive  sublimate ;  under  its  use  as  an  antiseptic  I  have 
known  the  bacilli  disappear  from  the  urine  and  the  ulcers  heal.  It 
must  be  used  in  a  dilute  form;  1  in  20,000  parts  is  strong  enough 
to  begin  with.  In  operations  on  the  interior  of  the  urethra,  where  a 
wound  is  inflicted  or  the  canal  is  abraded,  I  generally  leave  an  ounce 
or  two  of  this  solution  in  the  bladder  so  as  to  act  as  a  protection  to 
the  sore  by  sterilizing  the  first  portion  of  urine  that  is  passed,  and 
connect  immunity  from  rigors  and  fever  principally  to  this  practice. 
For  the  same  purpose,  in  tubercular  ulceration  of  the  bladder,  a  solu- 
tion of  iodoform  in  mucilage,  in  the  proportion  of  five  grains  to  an 
ounce,  is  used,  and  I  have  frequently  seen  good  from  it,  but  the  offen- 
sive smell  of  the  drug  is  an  inconvenience.  In  free  hemorrhage  from 
the  bladder,  injections  of  extract  of  witch  hazel  and  hot  water  have 
proved  of  service,  but  as  a  rule  the  less  we  interfere  instrumentally  in 
these  cases  the  better.  To  wash  out  a  clot  causing  irritation  to  the 
bladder  there  are  no  better  means  than  warm  water  and  Clover's 
catheter  and  suction  bottle  used  for  withdrawing  debris  after  lithotrity. 

When  washing  out  the  bladder  care  should  be  taken  to  examine 
the  fluid  employed  in  the  process,  when  expelled,  by  putting  it  into 
a  glass  receptacle.  So  long  as  flakes  or  masses  of  mucus  and  lymph 
are  seen,  we  have  evidence  of  material  existing  which  can  cause  and 
maintain  bacterial  life.  Further,  the  microscope  shows  that  such 
products  of  inflammatory  action  going  on  in  the  bladder  are  capable 
of  acting  as  minute  foreign  bodies,  and  of  furnishing  nuclei  upon 
which  phosphatic  concretion  may  take  place.  Especially  is  this  pre- 
caution necessary  after  a  stone  has  been  removed  from  the  bladder. 

Catheters  employed  for  these  and  all  purposes  should  be  carefully 
sterilized,  either  by  dry  heat  if  metal  instruments  are  used,  or,  if  flex- 
ible, by  immersing  them  in  solutions  of  nitrate  of  silver,  bichloride  of 
mercury,  or  boracic  acid.  This  is  a  precaution  that  it  is  well  to  take, 
though,  on  the  other  hand,  we  must  all  know  instances  where  the  indi- 
vidual has  practised  catheterism  for  a  number  of  years  with  no  other 
lubricant  than  his  saliva.  In  elderly  persons,  particularly^,  the  first 
introduction  of  the  catheter  should  be  accompanied  by  strict  antisep- 
tic precautions  when  this  is  possible.  It  is  quite  possible  to  under- 
stand how  disastrous  the  sudden  invasion  of  the  bladder  with  bacteria 
may  be. 


INFLAMMATION  OP  THE  BLADDER.  241 

Drainage  of  the  Bladder. — Following  upon  the  consideration  of  in- 
flammation and  suppuration  within  the  bladder,  it  will  be  convenient 
to  consider  certain  methods  of  drainage  which  are  advantageously 
adopted  in  connection  with  the  more  chronic  forms  of  these  disorders. 
There  are  some  bladders  so  shaped  as  to  require  treatment  on  precisely 
the  same  principles  as  are  adopted  in  connection  with  the  management 
of  chronic  abscesses.  Bladder  drainage  may  be  effected  by  an  open- 
ing above  the  pubes  or  through  the  perinseum.  The  former  will  be 
referred  to  when  describing  the  operation  of  supra-pubic  cystotomy. 
Perineal  puncture  of  the  membranous  urethra  for  this  purpose  is 
most  conveniently  effected  in  the  following  manner : 

The  patient  being  placed  in  the  lithotomy  position,  when  under 
an  ansesthetic,  a  centrally  grooved  staff  is  passed  into  the  bladder. 
The  correctness  of  the  position  of  the  instrument  being  verified  by 
the  finger  in  the  rectum,  the  perinseum  is  punctured  by  a  long  finger 
knife  entering  in  the  median  line  one  inch  in  front  of  the  anus.  The 
cutting  side  of  the  blade  is  directed  toward  the  operator,  while  the 
point  is  made  to  penetrate  the  perinaeum  so  as  to  enter  the  groove  in 
the  staff  immediately  in  front  of  the  apex  of  the  prostate.  The  inci- 
sion thus  made  is  somewhat  enlarged  in  a  direction  toward  the  scro- 
tum, so  as  to  admit  with  ease  the  index  finger  of  the  other  hand.  The 
latter  is  then  introduced  into  the  wound,  and  the  staff  felt  for.  If 
this  has  not  been  sufficiently  bared  as  to  be  readily  distinguishable 
to  the  touch,  I  clear  the  way  by  the  use  of  a  blunt  knife  made  for  this 
purpose ;  then  a  Wheelhouse's  probe-pointed  cone-shaped  gorget  is 
run  along  the  groove  in  the  staff  so  as  to  prepare  the  way  for  the  fin- 
ger which  subsequently  follows.  The  staff  being  withdrawn,  a  pas- 
sage is  now  made  into  the  bladder  for  the  introduction  of  the  drain- 
ing-tube.  Thus  a  tube  exactly  fitting  the  wound  can  be  inserted 
without  incurring  risk  of  bleeding. 

I  will  now  notice  some  different  kinds  of  drainage-tubes  and  the 
manner  of  their  employment.  Among  the  various  means  that  are 
used  in  connection  with  the  operative  treatment  of  diseases  of  the 
urinary  organs,  the  drainage-tube,  in  relation  to  the  urine,  probably 
occupies  the  most  prominent  position.  It  is,  in  fact,  now  identified 
with  almost  every  procedure  of  importance.  We  see  its  use  in  con- 
nection with  injuries  of  the  urinary  apparatus,  more  particularly  in 
cases  of  rupture  of  the  urethra,  where  the  condition  of  the  scar  that 
follows  is  largely  influenced  by  the  kind  of  provision  made  for  the 
disposal  of  the  urine  while  repair  is  proceeding ;  in  the  treatment  of 
several  j)lastic  operations  on  the  urethra  as  well  as  the  bladder;  in 
the  cure  of  chronic  sui)i)urative  affections  of  the  several  parts  consti- 
tuting the  urinary  ai)i)aratus;  "in  pouching  and  sacculation  of  the 
Vol.  I.— 10 


242  HABEISON — DISEASES   OF  THE  BLADDER. 

bladder  both  with  and  without  stone ;  and  particularly  in  the  preven- 
tion of  some  distinctive  forms  of  fever  originating  in  this  system.  In 
these  as  well  as  in  other  directions  its  use  is  now  well  recognized. 

For  introduction  into  the  bladder  through  the  perineal  puncture, 
and  retention  in  this  position  for  the  first  forty-eight  hours  or  so, 
I  usually  select  a  gum-elastic  tube  with  a  metal  mount,  having  an 
opening  on  either  side  for  the  retaining  tapes  (Fig.  42) .     In  calibre 


Fig.  42.— Bladder  Drainage  Tube. 

they  are  about  as  thick  as  my  index  finger,  that  is  to  say,  they  fit  with 
some  accuracy  the  opening  they  are  intended  for,  though  I  generally 
have  some  of  different  sizes  by  me  in  case  the  wound  may  for  any 
reason  be  somewhat  larger  than  usaal.  Sometimes  a  suture  is  put 
into  the  perineal  opening  either  above  or  below  the  tube,  so  as  to 
make  it  fit  accurately  and  prevent  bleeding  or  oozing  by  the  side.  I 
use  them  in  the  same  way  after  median  cystotomy.  They  are  not 
necessary  after  the  lateral  operation,  except  sometimes  temporarily, 
to  restrain  hemorrhage  by  fitting  the  wound,  as  this  incision  into  the 
bladder  entails  a  condition  of  urinary  incontinence  for  some  days. 
These  tubes  are  not  to  be  passed  too  far  into  the  bladder,  hence  we 
should  have  at  hand  various  lengths  to  suit  different  depths  of  peri- 
neum. If  the  fit  is  accurate  there  is  not  likely  to  be  trouble  with  bleed- 
ing, or  necessity  for  a  ligature.  A  gum-elastic  tube  is  preferable  for 
.the  first  forty-eight  hours,  as  in  case  there  should  be  any  oozing  we 
have  something  solid  to  plug  upon.  At  the  expiration  of  this  period, 
a  soft  rubber  one  with  a  velvet  or  depressed  eye,  and  open  at  the  end 
is  substituted,  such  as  are  made  for  me  in  different  lengths  and  cali- 


FiG.  43.— Soft-Rubber  Drainage  Tube  for  the  Bladder. 

bres  by  Messrs.  Tiemann  &  Co.,  of  New  York  (Fig.  43) .  The  rubber 
drainage-tubes,  with  the  punched-out  eyes,  are  most  objectionable, 
as  the  mucous  membrane  of  the  bladder  is  liable  to  be  sucked  into 
them,  and  then,  when  they  are  withdrawn,  pain  and  perhaps  a  little 
bleeding  are  occasioned  by  the  sharp  edge  of  the  opening.  This  re- 
mark also  applies  to  rubber  catheters  of  all  kinds.     The  soft  tubes  are 


INTLAMMATION  OF  THE  BLADDEB.  243 

easily  retained  in  position  by  a  perineal  band,  to  which  they  can  be 
attached  either  by  a  safety-pin  or  tape.  In  some  cases  of  extremely 
pouched  or  sacculated  bladders,  where  the  urine  drained  with  some 
difficulty,  I  have  used  the  two  varieties  in  combination  with  advan- 
tage— that  is  to  say,  a  soft  rubber  tube  has  been  passed  through  a 
gum-elastic  one,  on  the  principle  of  the  double  tracheotomy  tube. 
Where  it  has  also  been  found  necessary  to  wash  out  pockets  in  the 
bladder  this  has  proved  more,  effectual  than  the  single  tube.  After 
the  first  forty-eight  hours,  whatever  tube  is  used  for  drainage,  the 
bladder  should  be  washed  out  through  it,  and  then  the  tube  removed 
and  changed.  Care  should  always  be  taken,  on  replacing  the  tube 
finally,  to  test  it  with  a  syringe,  and  to  see  that  it  works  accurately. 
For  douching  the  bladder  in  connection  with  drainage-tubes  nothing 
is  better  than  a  hydrostatic  tank  and  a  vulcanite  tap  at  the  end  of  the 
tubing,  by  which  means  the  supj)ly  and  force  of  whatever  lotion  is 
used  can  be  regulated  without  producing  any  jar  or  sudden  concus- 
sion. During  the  first  forty-eight  hours  I  usually  let  the  urine  drain 
into  a  pad  of  wood-wool  or  some  antiseptic  absorbent  material  which 
can  be  frequently  changed.  After  this,  when  the  flow  is  established, 
the  patient  may  be  kept  quite  dry  by  attaching  a  piece  of  rubber  tub- 
ing to  the  metal  nozzle  of  the  drainage-tube,  by  which  the  urine  is 
conveyed  into  some  suitable  receptacle  between  the  patient's  legs,  or 
even  outside  the  bed.  No  drainage  can  be  perfect  when  the  bed  is  of 
such  a  shape  as  to  cause  the  patient  to  lie  in  a  hole ;  the  buttocks 
should  be  slightly  elevated,  and  drainage  favored  by  raising  the  head 
of  the  bed.  The  latter  can  easily  be  done  by  a  brick  or  a  wooden 
block.  A  little  experience  soon  shows  how  all  these  details  may  be 
attended  to,  as  much  importance  js  attached  to  them.  The  length  of 
time  drainage  should  be  carried  on  depends  on  the  nature  of  the  case. 
Where  the  urine,  to  commence  with,  is  alkaline  and  ammoniacal  or 
offensive,  it  will  at  all  events  be  required  until  the  excretion  is  dis- 
charged in  a  normal  condition.  I  have  tried  other  kinds  of  drainage- 
tubes,  including  those  made  of  glass  or  of  metal,  but  I  find  nothing 
so  efficient  as  those  I  have  mentioned. 

There  is  a  vulcanite  tube  with  a  movable  collar  described  by  Dr. 
F.  S.  Watson,  of  Boston,  U.  S.  A.  ("The  Operative  Treatment  of  the 
Enlarged  Prostate"),  which  will  be  found  useful  in  some  cases  where- 
the  bladder  is  much  pouched  behind  a  large  prostate.  The  end  of 
the  instrument  lies  in  this  dip,  and  thus  perfect  drainage  as  well  as 
provision  for  irrigation  of  this  portion  of  the  bladder  are  secured. 
By  the  movable  collar  the  instrument  can  be  at  once  adapted  to  any 
depth  of  perinseum. 


244  haerison — diseases  of  the  bladder. 

Eetention  op  Ueine. 

The  bladder  being  tlie  receptacle  for  urine,  we  may  consider  liere 
the  treatment  of  this  condition  so  far  as  it  relates  to  a  more  or 
less  distended  condition  of  the  viscus  as  arising  from  an  obstacle  in 
front  to  the  natiiral  evacuation  of  the  urine.  These  causes  are  for  the 
most  part  prostatic  and  urethral,  and  under  these  headings  will  receive 
separate  considerations.  To  empty  the  bladder  in  cases  where  ca- 
theterism  is  found  to  be  imi)ossible  or  inexpedient,  various  methods 
are  employed,  the  routes  being  selected  to  avoid  injuring  the  jjerito- 
nseum. 

Supra-Pubic  Puncture  or  Paracentesis. — This  is  probably  the  best 
for  the  purpose  of  meeting  an  emergency  of  this  kind.  It  consists  in 
puncturing  the  distended  viscus  with  a  fine  trocar  and  evacuating  the 
urine  with  an  aspirator. 

In  this  operation  there  are  two  points  to  be  remembered :  (1)  to 
use  a  fine  needle  only,  and  (2)  to  keep  near  to  the  bone,  and  so  avoid 
puncturing  the  peritonaeum.  The  line  at  which  the  reflection  takes 
place  is  variable,  but  a  space  of  at  least  half  an  inch  usually  exists 
above  the  pubes  where  the  needle  may  be  introduced  with  safety. 
This  area  is  increased  when  the  bladder  is  distended. 

Where  the  chance  of  restoring  the  urethra  is  only  remote,  as  in 
some  chronic  cases  of  stricture.  Cock's  operation  of  tapping  the 
urethra  at  the  apex  of  the  prostate  may  be  resorted  to  with  advan- 
tage where  urgent  retention  occurs.  I  occasionally  see  a  patient  upon 
whom  I  performed  this  operation  many  years  ago.  He  had  endured 
all  the  vicissitudes  that  could  happen  to  the  subject  of  a  bad  stricture, 
but  since  this  operation  he  has  enjoyed  perfect  health  and  comfort  at 
the  expense  of  micturating  through  the  perinseum.  Tapping  the  blad- 
der from  the  rectum  may  now  be  regarded  as  an  obsolete  operation. 

Tapping  the  Bladder  through  the  Enlarged  Prostate. — This  is  a 
method  I  described  some  years  ago  and  which  is  practised  in  the  fol- 
lowing manner :  The  patient  being  placed  in  the  lithotomy  position, 
under  ether,  a  specially  made  trocar  with  a  silver  cannula  is  introduced 
in  the  median  line  of  the  perineum  and  pushed  steadily  through  the 
prostate  into  the  bladder  while  the  left  index  finger  is  placed  in  the 
rectum  to  serve  as  a  guide.  The  trocar  is  then  withdrawn  and  the 
cannula,  made  for  the  purpose,  is  retained  as  a  permanent  vent.  This 
proceeding  has  been  followed  by  some  excellent  results,  including 
shrinkage  of  the  enlarged  prostate  where  this  condition  has  been  the 
cause  of  the  retention  of  urine.  Commenting  upon  this  method,  the 
late  Professor  Gross  remarks :  "  When  the  bladder  is  chronically  in- 
flamed, from  enlargement  of  the  prostate  gland,  tapping  may  be  per- 


EXTROYEESION  OP  THE  BLADDER.  245 

formed  through,  this  organ,  as  was  recently  suggested  and  success- 
fully practised  by  Mr.  Eeginald  Harrison.  My  conviction  is  that 
this  operation  is  destined  to  come  into  general  use  in  this  class  of 
cases,  of  such  frequent  occurrence  in  advanced  life,  and  a  source  of 
so  much  suffering"  ("A  System  of  Surgery,"  sixth  edition,  1882,  vol. 
ii.,  p.  703). 

MALFORMATIONS      AND      STRUCTURAL     ALTERA- 
TIONS  IN   THE   FORM   OF   THE   BLADDER. 

Aesence  of  the  Bladder. 

Complete  absence  of  a  bladder  or  of  an  independent  receptacle 
for  urine  is  occasionally  though  rarely  met  with,  the  ureters  opening 
by  the  umbilicus,  in  the  urethra  or  vagina,  or  into  the  rectum.  Where 
the  viscus  has  been  entirely  absent  I  am  not  aware  of  any  attempts  to 
construct  one  which  have  been  sufficiently  successful  to  deserve  men- 
tion. 

Double  Bladders. 

Two  cavities — or  more  correctly  speaking,  bladders  with  a  septum 
— have  been  described.  A  remarkable  case  of  this  kind  is  recorded  by 
Dr.  A.  P.  Smith,  of  Baltimore, "  where,  on  examining  the  patient  be- 
cause of  frequent  micturition,  it  was  discovered  that  he  had  a  double 
penis  with  bladders  to  correspond,  and  his  symptoms  were  explained  by 
the  presence  of  a  stone  in  one  of  the  receptacles  which  was  successfully 
removed  by  lithotomy.     Yan  Buren^®  describes  a  similar  deformity. 

Extroversion  of  the  Bladder. 

Among  the  most  distressing  deformities  to  which  the  human  body 
is  liable  is  that  where  the  roof  of  the  urethra  is  absent  in  conjunction 
with  fission  and  extroversion  of  the  bladder.  No  more  deplorable 
condition  can  be  imagined,  for  not  only  does  the  individual,  more 
frequently  of  the  male  kind,  possess  sexual  desire  he  is  unable  to 
gratify,  but  the  function  of  micturition  is  carried  on  in  such  a  way 
as  to  be  a  constant  source  of  personal  distress  as  well  as  of  annoy- 
ance to  others.  Here  not  only  are  the  parts  fissured  from  the  blad- 
der downward,  including  the  symphysis  pubis,  but  the  bladder  pre- 
sents the  appearance  of  a  fungating  mass.  The  orifices  of  the  ureters 
can  generally  be  distinctly  made  out  by  the  urine  dropping  from 
them,  while  the  fissured  penis  projects  at  the  base  of  the  mass  like  a 
spout.  The  prostate  is  rudimentary.  As  already  noticed,  I  can  find 
no  record  of  any  male  with  this  deformity  who  api)ears  to  have  devel- 
oi)ed  a  large  i^rostate.     To  remedy  this  condition  various  means  have 


246  HAERISON — DISEASES  OF  THE  BLADDER. 

been  employed.  Of  these  I  would  mention  certain  plastic  operations, 
having  for  their  object  the  closing  in  of  the  protruding  bladder  so  as 
to  form  a  receptacle  for  the  urine  and  a  covering  for  the  parts.  To 
the  late  Mr.  John  Wood  ^^  we  are  indebted  for  what  has  been  done  in 
this  direction,  and  a  reference  should  be  made  to  his  papers  by  any 
one  undertaking  an  operation  of  this  kind.  Various  plans  have  been 
tried,  having  for  their  object  the  diverting  of  the  urine  by  a  fistulous 
track  into  the  rectum,  but  I  do  not  know  of  any  results  thus  obtained 
which  would  induce  me  to  repeat  these  procedures.  An  article  on  this 
point,  containing  a  number  of  experimental  observations,  has  recently 
been  published  by  Dr.  E.  H.  Eeed."  Mr.  G.  H.  Makins"  has  re- 
corded a  case  where,  by  means  of  a  preliminary  division  of  the  sacro- 
iliac synchondrosis,  he  succeeded  in  diminishing  the  area  above  the 
pubes  which  required  covering  in  by  a  subsequent  plastic  operation. 
Such  a  proceeding,  however,  can  only  be  resorted  to  in  early  life, 
Professor  Trendelenburg  "  placing  the  limit  of  age  at  five  as  being  the 
most  suitable.  On  reviewing  what  has  thus  been  done  for  this  class  of 
deformities  I  am  disposed  to  think  that  its  relief  will  eventually  work 
out  most  advantageously  in  the  following  way :  By  (1)  the  establish- 
ment of  a  lumbar  fistula  with  one  kidnej^  preferably  the  right  one,  and 
(2)  the  removal  of  the  opposite  kidney  as  soon  as  the  urinary  fistula 
has  been  rendered  permanent.  In  this  way  the  whole  of  the  urine 
would  be  voided  through  one  fistula,  means  being  taken  to  collect  the 
excretion  as  it  escapes.  Dr.  Gross  "  refers  to  a  case  mentioned  by 
Mr.  Henry  Morris,  "where  about  ten  ounces  of  urine  were  passed 
daily  into  a  receiver  adapted  to  the  loin,  the  patient  suffering  neither 
inconvenience  nor  discomfort."  After  the  formation  of  one  permanent 
lumbar  fistula,  the  bladder  surface  being  no  longer  saturated  with 
urine,  it  would,  I  believe,  be  comparatively  easy  not  only  to  close  in 
the  protruding  mucous  surface,  but  further,  under  these  altered  con- 
ditions, to  make  a  penis  out  of  the  fissured  one  which  might  permit 
of  the  performance  of  the  sexual  act.  By  the  estabKshment  of  a  sin- 
gle renal  fistula  in  accordance  with  such  a  plan,  or  some  modification 
of  it,  as  I  have  endeavored  to  indicate,  there  seems  some  hope  of 
ameliorating  the  state  of  persons  suffering  in  this  way.  To  collect 
the  urine  as  it  drops  from  the  lumbar  fistula,  an  apparatus  such  as 
Dr.  Meyer  ^'  suggests,  in  the  shape  of  "  a  bustle"  as  worn  by  ladies, 
might  be  employed.  Of  mechanical  appliances  for  the  relief  of  the 
deformity  under  consideration,  I  can  speak  favorably  of  an  apparatus 
made  by  Messrs.  Tiemann  &  Co.,  of  New  York.  It  consists  of  a 
metallic  or  hard-rubber  shield  for  application  over  the  exstrophied 
bladder,  to  the  lower  extremity  of  which  an  elastic  tube  is  attached 
leading  to  a  bag  buckled  to  the  thigh  for  collecting  the  urine. 


patent  ueachus — hernia  of  the  bladder.  247 

Patent  Urachus. 

A  urinous  discharge  from  the  navel  is  occasionally  met  with,  and 
may  be  due  to  a  patent  condition  of  the  urachus,  a  structure  extend- 
ing from  the  fundus  of  the  bladder  to  the  umbilicus,  and  retaining 
the  tubular  character  of  the  allantois  till  about  the  thirtieth  week  of 
foetal  life.  Subsequently  it  becomes  obliterated  and  ceases  at  birth, 
except  in  some  few  instances,  to  have  any  tubular  connection  with  the 
bladder.  When  the  patency  of  the  tube  remains  the  patient  is  to  all 
intents  the  subject  of  a  urinary  fistula  in  a  position  occasioning  much 
inconvenience.  To  effect  a  closure  of  this  opening  various  means  have 
been  employed,  including  the  application  of  the  cautery,  and  the  vivi- 
fying of  the  walls  of  the  sinus  with  the  knife  and  the  introduction  of 
sutures.  As  in  the  treatment  of  other  urinary  fisfculse,  the  first  thing 
to  ascertain  is  that  there  is  no  mechanical  obstacle  to  the  escape  of 
urine  along  the  natural  channel;  care  must  be  taken  that  this  is  not 
impeded  in  the  male  by  a  phimosis,  a  contracted  meatus,  or  a  ure- 
thral calculus,  which  are  the  commoner  associations  of  a  patent  ura- 
chus. In  the  female  it  has  been  suggested  that  a  condition  of  tempo- 
rary incontinence  of  urine  by  over-dilatation  of  the  urethra  might 
be  sufficient  to  bring  about  a  cure. 

Hernia  of  the  Bladder. 

Cystocele,  or  hernia  of  the  bladder,  is  not  commonly  met  with. 
Instances  will  be  found  recorded  where  the  exploration  of  swellings 
and  prominences  in  the  region  of  the  pubes,  groins,  and  perineum 
has  proved  them  to  be  urine  cavities,  formed  by  hernial  displacements 
of  the  bladder.  Dr.  Ernst  Michels  records  the  following  case  of 
extra-peritoneal  vesical "  hernia : 

A  man,  aged  48  years,  was  admitted  into  the  London  German  Hos- 
pital suffering  from  inguinal  hernia  on  both  sides.  On  the  left  side 
the  radical  operation  was  done  without  difficulty,  but  on  the  right  it 
was  more  complicated.  At  last  what  appeared  to  be  the  empty  sac 
was  reached,  isolated  with  some  difficulty,  and  tied  at  its  neck  and  cut 
away.  The  stump  was  put  back  into  the  abdomen  and  the  inguinal 
ring  closed.  Twenty -four  hours  afterward  the  patient  began  to  com- 
plain of  pain  in  the  hypogastrium,  and  the  urine  contained  blood.  It 
was  evident  now  that  what  had  been  taken  for  and  treated  as  an  empty 
hernial  sac  was  in  reality  an  extra-peritoneal  diverticulum  of  the 
bladder.  The  abdomen  was  opened  at  once,  the  bladder  fully  ex- 
posed, and  a  wound  discovered  in  its  peritoneal  part  which  was  closed 
by  a  double  row  of  sutures.  A  rubber  catheter  was  passed  into  the 
bladder  and  retained  for  six  days.  The  patient  made  an  uninter- 
rupted recovery. 


248  HAERISON— DISEASES  OF  THE  BLADDER. 

Mr.  Crosse  observes  that  persons  suffering  from  cystocele  in 
whatever  form  are  very  liable  to  calculus,  and  he  mentions  numerous 
instances  of  the  sort. 

Inversion  of  the  Bladder. 

There  is  a  deformity  in  the  female  where  the  bladder  becomes  in- 
verted, or  turned  inside  out,  and  protrudes  between  the  labia,  as  a 
vascular  mass.  In  a  case  recorded  by  Mr.  Crosse  "  the  patient  nar- 
rowly escaped  the  application  of  a  ligature  to  the  protrusion  on  the 
supposition  that  it  was  a  nsevus  or  vascular  growth.  Fortunately  he 
was  able  to  prevent  the  adoption  of  such  a  fatal  course;  for,  as  he 
remarks,  "  had  a  ligature  been  efficiently  applied  to  the  neck  of  the 
tumor,  as  was  contemplated,  the  bladder  would  have  been  removed, 
including  all  its  coverings,  the  ureters  cut  through  just  above  their 
terminating  orifices,  and  the  peritoneal  cavity  largely  opened."  On 
examining  this  tumor,  it  was  found  capable  of  being  reduced,  like  a 
hernia,  by  the  pressure  of  the  finger.  When  reduction  was  thus  ac- 
complished, a  passage  remained  through  which  the  tumor  on  retiring 
had  taken  its  course,  and  which  proved  to  be  the  dilated  urethra. 
This  reduction  appears  to  have  been  effectual,  for  Mr.  Crosse  re- 
marks :  "  During  the  short  time  the  patient  remained  under  my  notice 
there  was  no  relapse,  and  I  am  enabled  to  add  that  she  is  still  living, 
after  an  interval  of  sixteen  years,  and  is  a  healthy  young  woman, 
save  only  the  affliction  of  incontinence  of  urine,  with  which  she  has 
been  constantly  troubled,  but  without  any  relapse  of  the  vesical  dis- 
placement. " 

Hypertrophy  of  the  Bladder. 

The  increased  growth  of  the  muscular  coat  of  the  bladder,  as  the 
term  implies,  is  a  natural  consequence  arising  out  of  obstructed  mic- 
turition, as  is  best  exemplified  in  connection  with  urethral  stricture 
and  certain  forms  of  prostatic  obstruction.  It  cannot,  therefore,  in 
this  sense  be  regarded  as  a  disease.  The  growth,  however,  by  limit- 
ing the  capacity  of  the  bladder,  is  usually  accompanied  by  frequent 
micturition,  a  circumstance  which  sometimes  leads  to  the  cause  of  the 
hypertrophy  being  overlooked.  There  is  a  condition  which  has  been 
described  as  a  columniform  state  of  the  bladder,  in  which  the  interior 
presents  an  appearance  not  unlike  that  of  the  ventricles  of  the  heart, 
the  muscular  fibres  not  being  spread  out  uniformly  but  being  col- 
lected in  bundles  like  the  columnae  carnese.  In  this  way  depressions 
are  formed  within  the  interior  of  the  bladder  which  may  eventually 
develop  into  saccules  or  form  receptacles  in  which  small  calculi  from 
the  kidney  may  be  readily  concealed. 


atony,  sacculation,  and  pouching  of  the  bladder.         249 

Atony  of  the  Bladdee. 

This  is  a  term  wliicli  is  generally  used  to  indicate  tlie  inability  of 
the  viscus  to  void  its  contents  in  a  natural  manner.  It  is  most  fre- 
quently met  with  in  connection  with  prostatic  obstruction  and  occa- 
sionally as  a  consequence  of  neglected  organic  urethral  stricture  in  the 
adult  male.  In  the  majority  of  instances  the  cause  is  purely  mechan- 
ical, that  is  to  say,  if  the  obstruction  can  be  removed,  the  full  power 
of  the  bladder  may  return  even  after  very  considerable  periods  of  in- 
action. The  subject  of  atony  is  best  discussed  in  connection  with  the 
co-existing  circumstances  just  mentioned. 

Sacculation  and  Pouching  of  the  Bladder. 

Pressure  on  the  walls  of  a  reservoir  like  the  bladder  is  capable  of 
causing  certain  alterations  in  the  form  of  the  viscus  to  which  the  terms, 
(1)  sacculation  and  (2)  pouching,  have  with  some  indiscrimination 
been  applied. 

By  sacculation  is  understood  that  a  limited  portion  of  the  vesi- 
cal mucous  membrane  becomes  herniated  or  prolapsed  through  the 
interstices  of  the  muscular  network  surrounding  it,  and  thus  in- 
dependent sacs  of  various  shapes  and  dimensions  are  produced. 
Sacculations  of  the  bladder  may  occur  at  almost  any  point,  they 
may  be  intra-  or  extra-peritoneal,  they  are  met  with  at  all  periods 
of  life  from  birth  onward,  they  have  little  or  no  independent  means 
of  exercising  power  over  their  contents  as  by  contraction  of  their 
walls,  and  they  are  capable  of  being  called  into  existence  and  of  be- 
ing disposed  of  in  ways  not  unlike  those  which  are  more  commonly 
illustrated  by  intestinal  hernia.  The  causes  of  sacculation  may 
be  ranged  under  three  headings :  (1)  intra-uterine,  (2)  arising  from 
obstacles  to  micturition  within  either  the  prostate  or  the  urethra,  and 
(3)  traumatic.  As  Mr.i  Targett  has  recently  pointed  out,"  some  sac- 
culations are  of  a  congenital  nature  and  are  explainable  either  as  con- 
sequences of  intra-uterine  pressure  or  of  developmental  variations. 
The  most  frequent  causes  are,  however,  those  which  are  included 
under  the  second  heading  as  arising  from  the  pressure  exercised  in 
overcoming  an  obstacle  in  front  of  the  bladder.  This  can  be  readily 
understood,  especially  when,  as  is  often  the  case,  the  muscular  coat  of 
the  bladder  is  more  or  less  hypertrophied.  Traumatic  causes  leading 
to  a  sudden  compression  of  a  distended  bladder  have  in  some  in- 
stances which  have  come  under  my  observation  led  to  a  similar  con- 
sequence. 

The  diagnosis  of  sacculation  is  not  always  easily  made.   In  some  in- 


250  HAEEISON — DISEASES  OF  THE  BLADDER. 

stances  we  have  notliing  to  guide  us  but  the  fact  that  the  movement 
of  a  catheter,  preferably  a  soft  one,  may  unmistakably  indicate  the 
existence  within  the  area  of  the  bladder  of  more  than  one  distinct  re- ' 
servoir  for  urine.  In  one  or  two  instances  not  only  was  I  able  to  rec- 
ognize the  probability  of  a  sac  in  this  way,  but  there  was  a  marked 
difference  in  the  appearance  of  the  sample  of  urine  removed  from  the 
two  compartments.  Guthrie,"  to  whom  we  are  indebted  for  a  de- 
scription of  this  condition,  observes :  "  In  one  gentleman  the  existence 
of  one  or  more  pouches  of  this  kind  became  evident  on  injecting  the 
bladder ;  twelve  ounces  of  warm  water  could  be  thrown  into  it  before 
much  uneasiness  was  produced,  but  on  drawing  it  off  ten  ounces  only 
could  be  obtained,  and  rarely  the  whole  twelve  even  by  change  of  posi- 
tion." Careful  examination  of  the  contiguous  parts  about  the  bladder 
may  sometimes  tend  to  the  detection  of  sacculation.  The  size  of 
these  diverticula  is  sometimes  so  considerable  and  the  direction  they 
take  so  unusual  that  in  investigating  growths  and  swellings  in  the 
neighborhood  of  the  pelvis  we  should  not  forget  to  test  the  state  of  the 
bladder  by  the  preliminary  use  of  a  catheter.  A  pelvic  tumor  has  in 
this  way  been  made  to  disappear.  The  presence  of  these  sacs  often 
occasions  serious  inconvenience  to  the  patient  and  embarrassment  to 
the  surgeon.  They  are  spaces  in  which  urine  collects  and  decom- 
poses, not  infrequently  calculi  descending  from  the  kidney  are  trapped 
and  concealed  by  them,  and  in  some  instances  by  retaining  sharp 
fragments  of  stone  after  lithotrity  they  have  contributed  to  the  pro- 
duction of  a  fatal  cystitis.  It  must  not  be  forgotten  that  these 
pouches,  either  by  impaction  with  calculous  matter  or  by  decompo- 
sition of  the  urine  for  which  they  are  the  receptacles,  may  undergo 
acute  suppurative  inflammation  and  by  bursting  within  the  pelvis 
occasion  a  most  serious  cellulitis. 

Saccules  most  frequently  come  into  prominence  as  complications 
in  connection  with  other  disorders.  .  Of  these  I  may  mention  stone, 
enlargement  of  the  prostate,  and  cystitis.  Calculi  in  the  bladder  thus 
complicated  represent  a  state  of  affairs  where,  as  a  rule,  the  stone 
should  be  removed  by  a  supra-pubic  cystotomy  and  the  sacculation 
dealt  with  by  drainage.  This  is  obvious  not  only  for  the  reason  that 
the  latter  may  render  a  complete  lithotrity  impossible,  but  that,  by 
retaining  fragments  and  keeping  up  cystitis,  they  favor  the  speedy 
reformation  of  the  stone.  To  determine  the  presence  of  a  sacculus  in 
the  bladder  where  there  are  sufficient  grounds  to  demand  this,  and  with 
the  object  of  treating  it  and  bringing  about  its  contraction  by  drain- 
age, if  its  removal  is  found  to  be  impossible,  exploration  of  the  blad- 
der by  the  supra-pubic  route  might  with  advantage  be  oftener  re- 
sorted to. 


POUCHING  OF  THE   BLADDEB. 


251 


By  pouching  of  tlie  bladder  (Fig.  44)  is  understood  tliat  a  depres- 
sion is  formed  in  the  most  dependent  portion  of  the  viscus  in  which 
the  whole  thickness  of  the  wall  is  involved.  It  is  for  the  most  part 
met  with  in  the  senile  adult  bladder  in  connection  with  hypertrophy 
of  the  prostate  and  occasionally  as  a  consequence  of  the  pressure  ex- 
ercised by  the  presence  of  a 
stone.  Mr.  Buckston  Browne" 
has  illustrated  how  such  a 
pouch  may  be  the  means  of 
containing  as  well  as  conceal- 
ing one  or  more  stones.  These 
pouches,  when  complicated 
with  calculus  and  an  enlarged 
prostate,  not  infrequently  ren- 
der the  selection  of  lithotomy 
a  necessity.  A  pouch  that  has 
once  held  a  stone  for  some 
time  is  seldom  fitted  to  hold 
anything  else,  and  consequent- 
ly an  attempt  should  be  made 
to  dispose  of  it  by  some  ade- 
quate form  of  bladder  drainage. 
In  the  general  treatment  of 
pouching  and  sacculation  of 
the  bladder,  when  not  compli- 
cated with  stone,  I  must  add 
my  testimony  to  the  great  bene- 
fit that  has  sometimes  followed  sea-voyages.  I  have  known  thick 
cystitic  urine,  due  to  the  pollution  of  the  general  cavity  of  the  blad- 
der by  the  contents  of  a  stagnant  sac,  entirely  recover  itseK  when 
placed  under  these  conditions.  The  constant  movement  of  the  ship 
both  by  day  and  night,  and  in  whatever  position  the  body  may  oc- 
cupy, renders  stasis  of  any  of  the  fluids  of  the  body  impossible,  and 
thus  one  element  necessary  for  decomposition  is  removed.  The  im- 
munity of  seamen  from  stone  and  certain  bladder  affections  may  in 
some  measure  be  due  to  this.^"  In  one  instance  at  present  under  my 
observation  where  there  is  very  little  doubt  the  patient  has  a  saccu- 
lated bladder,  the  urine  is  invariably  clear  and  normal  when  he  is  at 
sea,  and  turbid  and  offensive  when  he  is  on  shore  for  any  length  of 
time.  Yet  in  other  respects,  as  far  as  I  can  judge,  the  conditions  are 
the  same. 


Fig.  44.— Pouching  of  the  Bladder. 


252  haerison — diseases  of  the  bladder. 

Tumors  of  the  Bladder. 

Tlie  bladder  wall  is  developed  partly  from  hypoblast  and  p^ly 
from  mesoblast;  consequently,  on  the  embryological  theory  of  the 
origin  of  morbid  growths,  we  may  expect  to  find  connective-tissue, 
vascular,  and  epithelial  tumors.  It  is  interesting  to  note,  in  associa- 
tion with  paj^illoma  of  the  bladder,  that  the  allantois,  the  hypoblast 
lining  of  which  gives  rise  to  the  epitheKal  coating  of  the  bladder,  is 
also  the  source  of  the  chorionic  villi,  the  most  perfect  example  of 
physiological  papillary  growths.  The  classification  of  bladder  and 
prostate  tumors  adopted  here  is  similar  to  that  proposed  by  Mr. 
Paul,"  in  a  paper  read  before  the  British  Medical  Association 
in  1883.  The  former  will  be  considered  in  the  following  order: 
(1)  Myoma;  (2)  Fibroma;  (3)  Myxoma;  (4)  Sarcoma;  (5)  Papilloma; 
(6)  Carcinoma. 

(1)  Myoma  of  the  bladder  is  a  very  rare  growth,  met  with  chiefly 
in  the  form  of  nodules  encapsuled  in  the  subiiiucosa.  It  is  composed 
of  unstriped  muscular  fibres,  resembling  uterine  or  prostatic  myoma. 
Gases  are  recorded  by  Gussenbauer'"  and  Volkmann.^'  The  muscular 
fibres  are  sometimes  mixed  with  a  good  deal  of  fibrous  tissue,  when 
the  tumor  is  called  a  fibro-myoma. 

(2)  Fibroma  and  (8)  myxoma  may  be  regarded  as  essentially  the 
same,  myxoma  being  merely  a  fibroma,  the  cell  substance  of  which 
has  undergone  mucoid  transformation.  The  great  majority  of  these 
growths,  which  are  by  no  means  common,  are  polypoid,  and  the  softer 
varieties  approach  very  closely  in  structure  the  denser  papillary 
growths.  A  true  fibroma,  however,  would  originate  in  the  deeper 
layers  of  the  submucosa  or  muscular  coat,  and  be  covered  by  the  dis- 
tended but  otherwise  normal  epithelial  layer ;  whereas  in  a  papilloma 
the  essentially  epithelial  character  of  the  growth  is  evident  from  the 
large  share  taken  by  the  epithelium  in  its  formation.  Fibromata  and 
myxomata  constitute  the  majority  of  so-called  bladder  polypi.  The 
former  occur  in  adults,  and  the  latter  usually  in  young  children,  in 
whom  they  are  probably  generally  congenital. 

(4)  Sarcoma  of  the  bladder  is  less  frequent  than  carcinoma.  The 
round-celled  variety  is  the  form  in  which  it  usually  occurs.  Mr. 
Paul,  in  the  paper  before  quoted,  mentions  but  one  specimen,  the 
same  described  by  Mr.  Eodger  Williams. "  This  growth  occurred  in  a 
hernial  sacculus  of  the  bladder,  and  was  composed  of  round  and  spindle 
cells.  It  was  believed  to  be  a  sarcoma  which  had  become  inflamed. 
Two  cases  of  lympho-sarcoma  of  the  bladder  have  been  described  by 
Mr.  Eve  and  Mr.  Ghaffey, "  and  the  former  in  the  same  communica- 
tion also  gives  an  account  of  a  mixed  or  myo-sarcoma  occurring  in  the 


TUMORS   OF  THE   BLADDER.  253 

muscular  coat  of  the  bladder.  The  lymplio-sarcoma  is  composed  of 
a  fine  fibrous  stroma,  the  meshes  of  which  are  occupied  by  rcmnd  cells 
with  large,  deeply  staining  nuclei  and  very  scanty  cell  protoplasm. 
Sarcomas  of  the  bladder  may  be  very  small,  scarcely  showing  on  the 
surface,  or,  as  in  Mr.  Eve's  case,  they  may  form  large  masses  pro- 
jecting into  and  partly  filling  the  bladder;  the  surface  may  be  ulcer- 
ated, but  is  apparently,  unlike  that  of  carcinoma,  never  villous. 

(5)  Papilloma. — As  the  mucous  membrane  of  the  bladder  is  desti- 
tute of  papillae,  the  term  papilloma,  as  applied  to  innocent  villous 
growths  of  this  viscus,  has  been  objected  to,  many  pathologists  hold- 
ing with  Virchow"'  that  they  should  be  termed  vascular  papillomatous 
fibroma.  As  the  papillary  outgrowths  are,  however,  clothed  by  a 
very  thick  layer  of  epithelium,  and  as  it  can  be  seen,  as  was  first 
pointed  out  by  Rindfleisch, "  that  in  the  more  delicate  of  the  villous 
tufts  the  basement  membrane  of  the  epithelium  rests  on  the  wall  of 
the  blood-vessel  without  the  intervention  of  any  fibrous  tissue,  it  may 
be  said  that,  although  many  villous  tumors  partake  to  a  greater  or 
less  extent  of  the  characters  of  a  papillation  of  a  fibrous  growth,  they 
are  mostly  best  described  as  true  papilloma ;  and  in  this  connection 
it  is  well  to  recollect,  as  already  mentioned,  that  the  extra-abdominal 
portion  of  the  allantois  which  forms  the  chorion  is  normally  provided 
with  papillae,  hence  it  is  not  an  unlikely  occurrence  for  them  to  be 
met  with  in  the  bladder  (the  intra-abdominal  portion  of  the  allantois) 
as  a  pathological  occurrence. 

Papilloma  or  villous  tumor  (sometimes  incorrectly  called  villous 
cancer  of  the  bladder)  is  met  with  chiefly  on  the  trigone  and  in  the 
neighborhood  of  the  ureters ;  in  other  words,  like  warty  growths  in 
other  situations,  around  the  orifices.  It  is  composed  of  numerous 
long,  filamentous,  branching  processes,  forming  a  cauliflower-like 
growth  of  a  variable  consistency  depending  on  the  amount  of  connec- 
tive-tissue framework  supporting  the  epithelial  growth  and  vessels. 
On  microscopic  examination  the  processes  are  seen  to  be  more  or  less 
made  up  of  a  delicate  fibrous  stroma,  containing  thin- walled  and  wide 
— sometimes  varicose — blood-vessels,  and  not  rarely  unstriped  muscle 
cells,  the  whole  forming  an  upward  prolongation  of  the  submucosa, 
covered  with  stratified  epithelium.  The  growth  does  not  extend  into 
the  deeper  layers  of  the  mucous  membrane,  and  the  epithelium  every- 
where rests  oA  a  basement  membrane.  While  the  growth  retains  this 
structure  it  is  in  no  sense  malignant  or  cancerous,  but  papilloma  here 
as  elsewhere  is  liable,  if  not  removed,  or  if  recurring  after  removal, 
to  grow  more  and  more  dense  and  fleshy  in  character,  and  ultimately 
to  Vjecome  a  carcinoma.  This  is  well  illustrated  in  a  case  related  by 
Mr.  Paul,  where  a  pajjilloma  which  had  been  removed  several  times 


254  HAEEISON — DISEASES  OF  THE  BLADDEE. 

ultimately  caused  the  death  of  the  patient,  after  ten  years  of  occa- 
sional treatment,  and  the  growth  was  then  found  to  be  infiltrating  the 
bladder  wall  as  a  carcinoma.  It  is  to  be  remembered  that  where  a 
papilloma  overlies  a  carcinomatous  growth  in  the  submucous  and 
muscular  coats  of  the  bladder,  this  condition  does  not  necessarily 
depend  on  the  innocent  growth  having  taken  on  malignant  characters, 
since  it  is  not  very  rare  to  find,  as  is  well  shown  by  Cornil  and  Reli- 
quet,  that  carcinoma  may  be  associated  with  the  development  on  the 
overlying  surface  of  a  structurally  innocent  paj)illoma. 

The  delicate  and  friable  character  of  a  villous  tumor  renders  it  very 
liable  to  injury  from  the  contraction  of  the  bladder  in  emptying  it- 
self, not  only  by  the  action  of  friction  and  pressure  on  the  growth, 
but  also  by  the  congestion  of  the  capillary  loops  produced  by  the  con- 
traction of  the  muscular  coat.  In  this  way  hemorrhages  are  frequent, 
and  death  is  usually  due  to  anaemia  and  exhaustion.  In  other  cases 
the  position  of  the  growths  around  the  ureter  leads  to  chronic  ob- 
struction of  that  tube  and  hydronephrosis.  In  some  instances  where 
the  obstruction  is  more  acute,  suppurative  pyelonephritis  may  result. 
The  papillomas  of  the  bladder  are  subdivided  into  two  classes,  fim- 
briated papilloma  and  fibro-pax)iUoma.  In  the  former  the  stalk 
breaks  up  into  numerous  delicate  branches  presenting  the  well-known 
villous  appearance ;  in  the  latter  it  is  compact  and  sessile,  and  has  a 
more  dense  fibrous  structure. 

(6)  Carcinoma. — The  epithelial  lining  of  the  bladder  is  composed 
of  a  single  surface-layer  of  large-sized  squamous  cells,  with  underly- 
ing pear-shaped  and  round-ceU  layers.  It  is  also  provided  with  small 
racemose  mucous  glands,  most  numerous  near  the  neck  of  the  blad- 
der. It  wiU  be  seen  that  we  may  thus  expect  to  meet  with  two  varie- 
ties of  cancer  of  the  bladder :  (a)  epithelioma,  or  squamous-ceUed 
carcinoma,  and  (&)  glandular-celled  carcinoma.  Speaking  clinically, 
the  former  would  usually  be  termed  encephaloid  cancer,  while  the 
latter  might  be  encephaloid  or  scirrhus — in  other  words,  soft  or  hard. 
These  clinical  terms,  however,  give  no  information  relative  to  the  in- 
timate structure  of  the  tumor,  but  indicate  only  its  rapidity  of  growth 
and  probable  degree  of  malignancy.  The  vesical  glands  might  be 
liable  to  innocent  adenoma  as  well  as  to  malignant  carcinoma.  So 
far  as  I  know  only  one  case  of  the  former  is  recorded,  viz.,  a  case  of 
papillary  adenoma,  removed  by  Kaltenbach'*  from  the  bladder  of  a 
woman  aged  forty-four  years. 

Dr.  J.  H.  Neale,  of  Leicester,  records  a  case''  of  mahgnant  tumor 
of  the  bladder  where  the  account  of  the  microscopical  features  of  the 
growths,  to  which  he  gives  the  name  of  adeno-encephaloid  cancer, 
indicates  a  glandular  as  distinct  from  a  squamous  epithelial  origin  for 


TUMOES  OF  THE  BLADDEE.  255 

the  growth.  The  ordinary  epithelioma  of  the  bladder  is  a  growth  of 
variable  size  and  extent,  either  limited  to  one  spot  from  which  it 
spreads,  or  diffuse,  occurring  in  a  variable  number  of  patches,  one 
usually  showing  evidence  of  being  the  primary  growth.  The  tumor 
is  not  encapsuled,  but  infiltrates  the  submucous  and  muscular  layers, 
spreading  to  the  peritonaeum,  the  bowel,  the  prostate,  or  even  extend- 
ing to  the  perinseum,  where  it  forms  a  fungating  mass.  This  latter  is 
liable  to  occur  in  cases  where  the  growth  has  been  partially  removed 
from  the  bladder  after  perineal  section,  the  cancer  invading  the  gran- 
idation  tissue  of  the  wound,  and  spreading  along  it  to  the  surface. 

The  mucous  membrane  over  the  growth  may  be  ulcerated  and  fun- 
gous, or  covered  with  papillary  excrescences,  showing  no  outward 
evidence  of  malignancy,  or  even  quite  smooth  and  apparently  unal- 
tered, in  the  smaller  patches.  The  stroma  of  the  growth,  composed 
of  the  tissue  of  the  submucous  and  muscular  layers,  with  more  or 
less  round-cell  infiltration,  is  full  of  alveoli  well  packed  with  epithe- 
lial cells,  following,  with  more  or  less  accuracy,  the  types  of  the  blad- 
der epithelium.  Psorosperms  have  been  met  with  in  the  epithelial 
cells,  and  by  some  are  regarded  as  the  cause  of  the  malignant  growth. 
They  are  described  and  figured  by  Albanian  in  his  work  on  tumors  of 
the  bladder  ("Les  Tumeurs  de  la  Yessie,"  Paris,  1892).  The  forma- 
tion of  "  cell  nests"  varies  much  in  different  specimens  and  even  in 
different  parts  of  the  same  specimen.  Colloid  degeneration  may  oc- 
cur in  primary  carcinoma  of  the  bladder,  but  is  by  no  means 
common. 

Secondary  Carcinoma. — Secondary  cancer  of  the  bladder  is  much 
more  common  than  primary  cancer.  It  is  usually  due  to  direct  inva- 
sion of  the  bladder  wall  by  growths  originating  in  the  prostate,  rec- 
tum, or  uterus.  In  either  case  the  growth  infiltrates  the  bladder 
wall,  and  may  cause  symptoms  such  as  vesical  tenesmus  and  haema- 
turia,  or  it  may  interfere  with  the  flow  of  urine  into  or  from  the  blad- 
der, with  corresjjonding  symptoms.  Indications  of  the  previous  ex- 
istence of  the  primary  growths  are  not,  as  a  rule,  wanting.  The 
structure  of  the  secondary  growth  is,  of  course,  a  repetition  of  that 
of  the  primary  one. 

Enchondroma. — Two  cases  of  enchondroma  of  the  bladder  have 
been  described,""  but  in  neither  case  does  the  description  render  it 
other  than  doubtful  that  the  growths  had  their  origin  in  that  viscus. 
A  case  of  vesical  angioma  is  described  by  Langhans." 

(jtjHtHof  tilt  BhAder. — Serous,  hyatid,""^  and  dermoid  cysts  of  the 
bladder  are  occasionally  met  with.  Serous  cysts  may  be  due  to  soft- 
ening of  a  myoma,  or  they  may  be  simply  cysts  formed  in  the  mu- 
cous membrane.     Hydatid  cysts  may  occur  in  the  bladder  wall  or  its 


256  HAEEISON — DISEASES  OP  THE  BLADDER. 

immediate  neighborliood  as  elsewliere.  Cases  are  from  time  to  time 
recorded  where  hairs  have  been  passed  in  the  urine.  In  some  cases 
the  hairs  doubtless  came  from  dermoid  cysts  of  the  ovary  which  had 
ruptured  into  the  bladder,  but  in  others  they  have  unquestionably 
originated  in  true  vesical  dermoid  cysts,  or,  as  in  Martini's  case," 
from  a  patch  of  true  skin  bearing  hair  follicles  and  forming  part  of 
the  bladder  wall.  Such  an  occurrence  would  depend  upon  a  develop- 
mental aberration,  by  which  a  portion  of  the  bladder  wall  had  been 
formed  by  the  ingrowth  of  epiblast  to  make  up  for  some  deficiency 
in  the  hypoblast. 

Bilobed  and  pouched  bladders  "^  and  hernial  saccular  protrusions 
of  the  mucosa  need  only  be  named  here.  Cysts  of  the  urachus  are 
not  very  infrequent. 

The  presence  of  the  bilharzia  hsematobia  sometimes  leads  to  the 
formation  within  the  bladder  of  fungating  masses  of  exudating  tissue, 
attended  with  profuse  hsematuria,  which  have  called  for  operative 
procedures  for  their  relief. 

TUMOES   OF  THE    PrOSTATE. 

As  the  prostate  is  composed  of  fibrous,  muscular  (unstriated) ,  and 
epithelium-lined  gland  tissue,  we  may  expect  to  meet  with  connective- 
tissue  tumors,  myoma,  adenoma,  and  carcinoma,  and  these  we  find  to 
be  the  new  growths  of  this  part. 

Myoma. — Unstriated  muscular  tumors  of  the  prostate  are  met  with 
as  small  encapsulated  groTvi;hs,  most  frequent  in  the  so-called  middle 
lobe,  or  as  large  masses  apparently  involving  the  whole  part.  Such 
a  case  was  Mr.  Spanton's,"^  where  a  mass  of  growth  the  size  of  a  fist 
was  removed  by  operation,  and  a  further  equally  large  mass  was  found 
at  the  autopsy.  It  closely  resembled  that  of  a  moderately  soft  uterine 
myoma,  and  in  this  connection  the  developmental  identity  of  the 
female  uterus  with  the  male  sinus  pocularis  and  its  immediately  sur- 
rounding muscular  fibre  is  to  be  noted.  Pure  myoma  of  the  prostate 
is  a  rare  growth.  The  encapsuled  tumors  usually  contain  a  consider- 
able admixture  of  glandular  tissue,  and  are  properly  called  adeno- 
myoma.  They  correspond  to  the  adeno-fibroma  so  frequently  met 
with  in  the  female  breast. 

Sarcoma  of  the  prostate  would  appear  to  be  the  form  of  new 
growth  most  frequently  met  with  in  this  part.  In  structure  it  may 
be  round-  or  spindle-celled,  or,  as  is  frequently  the  case  in  the  blad- 
der, a  lympho-sarcoma. 

Carcinoma  of  the  prostate  is  either  tubular  or  acinous,  and,  in 
either  case,  may  become  colloid.     Sections  of  it  show  a  sti'oma  com- 


TUMORS  OF  THE   PROSTATE.  257 

posed  mainly  of  unstriated  muscular  fibre,  containing  alveoli  filled 
witli  cells  resembling  those  of  the  prostatic  glands. 

Primary  carcinoma  of  the  prostate  is  not  of  such  rare  occurrence 
as  is  generally  supposed.  It  is  frequently  overlooked,  both  during 
life  and  after  death,  any  enlargement  or  induration  being  regarded  as 
merely  ordinary  hypertrophy.  In  several  instances  which  I  have  seen, 
where  the  diagnosis  was  verified  by  microscopical  examination,  the 
disease  was  marked  by  slow  progress  and  by  the  slightness  of  the  local 
symptoms  that  were  present  throughout.  It  appeared  to  prove  fatal 
by  the  general  decay  that  was  induced,  rather  than  by  any  interfer- 
ence it  occasioned,  directly  or  indirectly,  with  the  function  of  mictu- 
rition, thus  contrasting  with  advancing  forms  of  ordinary  prostatic 
hypertrophy.     The  following  case  seems  to  illustrate  this : 

Case. — I  frequently  saw  a  gentleman,  aged  59,  in  1884,  who  suf- 
fered from  irritability  of  the  bladder,  which  he  could  not  completely 
empty.  He  was  losing  flesh,  becoming  pale,  and,  though  the  mental 
faculties  remained  vigorous  to  the  last,  he  constantly  complained  of 
pain  in  the  loins,  nates,  and  thighs.  In  the  course  of  a  few  weeks  he 
became  entirely  dependent  upon  the  catheter.  His  prostate  was  hard, 
nodular,  and  almost  insensitive  to  the  touch,  though  no  glands  in  the 
neighborhood  were  involved.  As  his  general  health  slowly  declined, 
minute  petechial  spots  appeared  on  various  parts  of  his  body,  and 
his  feebleness  gradually  increased.  Occasionally  he  passed  a  small 
quantity  of  blood  with  his  urine.  He  appeared  to  die  of  exhaustion, 
the  result  of  prolonged  blood-vitiation.  After  death  his  prostate  was 
examined  and  found  to  be  an  unmistakable  example  of  carcinoma. 
There  was  no  evidence  to  show  that  this  was  other  than  the  primary 
disease. 

Mr.  Bryant "'  has  recorded  a  case  of  fibrous  polypus  of  the  prostatic 
portion  of  the  urethra,  associated  with  profuse  hsematuria  and  pros- 
tatic enlargement,  where,  on  exploration  by  a  median  perineal  opera- 
tion, a  polypus  the  size  of  a  haricot  bean  was  removed.  After  a  some- 
what tedious  convalescnce  recovery  ensued,  and  eighteen  months  after 
the  operation  the  patient  was  well,  with  his  prostate  contracted  to  its 
original  size. 

The  prostate  is  frequently  the  seat  of  small  calcareous  deposits, 
which  have  been  described  under  the  name  of  prostatic  calculi.  They 
Xn'obably  represent  a  concreted  state  of  the  natural  secretion  of  the 
I)rostatic  glands. 

Tubercle  of  the  prostate,  which  is  first  miliary  and  then  caseous, 
may  be  mistaken  for  new  growth  if  care  be  not  taken  to  exclude  it  on 
clinical  grounds.  It  is,  as  a  rule,  secondary  to  tubercle  of  the  kidney 
and  bladder  or  of  the  testicle,  most  frequently  the  latter.  Prostatic 
cysts  may  be  either  retention  cysts  of  the  i)ro8tatic  follicles,  or,  what 
Vol.  I.— 17 


258 


HAERISON — DISEASES   OF  THE  BLADDER. 


is  more  usual,  urethral  diverticula,  as  in  a  case  recorded  by  Mr.  W. 
Arbuthnot  Lane." 

Some  growths  involving  the  urethra  have  been  already  referred  to 
in  connection  with  malignant  or  cancerous  strictures.  Polypi  of  an 
innocent  kind  are  sometimes  met  with  in  this  position.  Mr.  W.  H. 
Brown  **  records  an  instance  which  is  unique : 

Case. — The  patient,  a  male,  aged  18,  was  under  observation  dur- 
ing 1891,  for  difficult  and 
painful  micturition.  The 
pain  was  referred  to  the 
end  of  the  penis,  and 
there  was  frequent  incon- 
tinence at  night  and  drib- 
bling of  the  urine  when 
walking  about.  On  one 
occasion,  whilst  straining 
to  urinate,  about  two 
ounces  of  bright  blood 
were  expelled.  On  his 
attempting  to  pass  urine 
the  stream  was  very 
small,  and  a  curious  bal- 
loon-shaped swelling  just 
over  the  urethra  at  the 
junction  of  the  penis  with 
the  scrotum  was  observed. 
The  urine  was  natural. 
The  boy  died  of  extensive 
cystic  disease  of  the  kid- 
neys. The  growth  in 
appearance  resembled  a 
polypus  and  was  attached 
behind  to  the  prostatic  re- 
gion in  the  posterior  wall 
of  the  bladder,  and  in 
front  to  the  urethra  as  shown  in  the  drawing  (Fig.  45) .  Mr.  Brown 
observes :  "  I  have  not  been  able  to  find  a  similar  record.  The  posi- 
tion of  the  tumor  and  its  twofold  attachment  are,  so  far  as  I  know, 
without  parallel." 

Diagnosis  and  Treatment  of  Tumors  of  the  Bladder  and  Prostate. 

For  clinical  purposes  relative  to  treatment  it  will  be  convenient  to 
consider  tumors  of  the  bladder  as  they  are  usually  presented  to  our 
notice.  We  can  recognize  three  periods  in  the  existence  of  many  of 
these  growths,  irrespective  of  the  question  of  degree  of  malignancy  or 
otherwise,  which,  though  not  defined  by  any  artificial  lines,  are  suf- 
ficiently distinctive  for  the  object  in  view.  These  stages  may  be 
spoken  of  as    (1)    quiescent;    (2)    symptomatic;    (3)    destructive.     I 


Fig.  45.— Polypus  of  the  Prostatic  Urethra. 


TEEATMENT   OP  TUMORS   OF   BLADDER  AND  PROSTATE.  259 

must  not,  however,  be  understood  to  imply  by  this  that  all  growths 
pursue  the  several  courses  I  have  thus  indicated.  Some,  so  far  as  we 
know,  are  quiescent  throughout,  being  only  accidentally  discovered 
either  during  life  or  after  death ;  others  terminate  existence  by  the 
symptoms  they  produce  rather  than  by  any  morbid  characteristics 
they  inherently  possess;  while  a  third  group,  like  cancerous  affec- 
tions, are  fatal  by  the  tissue  destruction  they  directly  effect,  and  the 
consequences  on  the  system  generally  arising  out  of  this.  With  this 
reservation  the  grouping  suggested  for  clinical  purposes  may  suffice. 

1.  The  Quiescent  Stage. — This  includes  the  early  stages  of  growths, 
where  they  proceed  up  to  a  certain  point  without  giving  any  specific 
indication  of  their  presence.  Some  of  the  innocent  tumors  of  the 
bladder  have  thus  remained  during  the  whole  period  of  their  exis- 
tence, instances  having  been  recorded  where  they  were  casually  dis- 
covered by  the  electric  cystoscope.  Other  examples  have  been  found 
in  autopsies  where  no  distinctive  history  appeared  to  have  been  con- 
nected with  them,  and  cases  are  known  in  patients  of  the  total  cessa- 
tion, after  varying  periods,  of  symptoms  which  seemed  to  be  those 
connected  with  villous  growths  or  papillomata.  Whether  their  disap- 
pearance was  due  to  an  inflammatory  act  within  the  bladder  or  to 
sloughing  it  is  impossible  to  say,  but  such  an  occasional  termination 
is  sufficiently  well  authenticated  for  acceptance.  The  evidence  that  a 
person  has  a  tumor  in  his  bladder  would  not  alone,  in  the  absence  of 
other  reasons,  warrant  operative  measures  being  taken  for  its  removal. 
Nor  does  the  persistence  of  a  single  symptom — such,  for  instance,  as 
occasional  hsematuria  without  causing  detriment  to  the  general  health 
— justify  the  performance  of  an  operation  involving  the  opening  of  the 
bladder  merely  on  the  presumption  that  some  growth  exists  within 
the  area  of  this  viscus  or  of  the  prostate.  Some  prostates  which  are 
enlarged  occasionally  bleed  just  as  a  hsemorrhoid  will  do,  and  with  as 
little  harm,  and  pieces  of  prostatic  hypertrophies  have  occasionally 
been  removed  as  growths  or  tumors  with,  I  believe,  insufficient 
reason. 

2.  The  Symptomatic  Stage. — The  larger  proportion  of  bladder  tu- 
mors sooner  or  later  pass  out  of  the  quiescent  condition,  and  enter 
upon  the  second  or  more  active  stage  of  their  existence.  Whether 
this  transition  is  slow  or  rapid,  gradual  or  sudden,  greatly  depends 
on  their  kind  as  well  as  on  the  accidents  and  contingencies  connected 
with  their  growth;  but  whether  innocent  or  malignant,  primary  or 
secondary,  the  majority  of  them  sooner  or  later  make  it  apparent  that 
life  will  eventually  be  destroyed,  either  by  persistent  hemorrhage  or 
ulceration,  or  by  the  degree  of  interference  with  micturition.  Con- 
tinuous or  intermittent  hemorrhage,  evidence  of  ulceration,  and  inter- 


260 


HAERISON — DISEASES   OF  THE  BLADDER. 


ference  with  micturition  are  the  symptoms  of  progressive  tumor  of 
the  bladder  which  may  be  sufficient  to  indicate  operative  interference. 
In  addition,  valuable  assistance  in  diagnosis  can  generally  be  obtained 
by  examination  of  the  bladder  from  the  rectum  and  with  the  sound, 
and  by  the  evidence  that  may  be  furnished  by  an  inspection  of  the 
growth.  By  the  rectum  the  finger  will  frequently  prove  that  the  pos- 
terior wall  of  the  bladder,  as  well  as  the  contiguous  portion  of  the 
bowel  or  prostate,  is  implicated  in  a  growth  of  an  irregular  form  and 
consistence,  partaking  of  the  characteristics  usually  associated  with 
the  physical  signs  of  malignancy.  Exploration  with  the  sound  will 
often  also  unmistakably  indicate  that  the  area  of  the  bladder  is  more 
or  less  encroached  upon  by  a  new  tissue  formation,  which  as  a  rule 
readily  bleeds,  even  under  delicate  manipulation.  Direct  evidence  is 
sometimes  afforded  by  the  microscopical  examination  of  portions  of 
growth  voluntarily  discharged  during  micturition  or  removed  in  the 
eye  of  a  catheter  or  by  any  other  instrument.  Too  much  importance 
must  not  be  attached  to  this,  in  the  absence  of  symptoms  of  a  corrob- 
orative nature. 

In  the  present  day  the  most  reliable  evidence  of  the  presence  and 
nature  of  a  tumor  within  the  bladder,  including  some  varieties  of 
prostatic  outgrowths, 
is  to  be  obtained  by 
the  illumination  of  the 
interior  of  the  viscus 
by  means  of  the  electric 
light  and  the  use  of  a      

suitable  speculum 
in  connection  with 
it.  The  mode  of 
doing  this  is  shown 
in  the  following 
figures  from  Albar- 
ran  (Figs.  46  and 
47) .  Apart  from 
the  question  of  di- 
agnosis, it  is  upon 
an  examination  of 
this  kind,  taken  in  conjunction  with  the  symptoms  each  case  pre- 
sents, that  conclusions  as  to  treatment,  more  particularly  in  reference 
to  operative  measures,  are  to  be  drawn  and  a  course  decided  upon. 
Ocular  inspection  obtained  in  this  way  has  now  almost  entirely  super- 
seded the  digital  explorations  which  were  practised  before  the  intro- 


FiGS.  46,  47.— Electrical  Illumination  of  the  Bladder. 


TREATMENT  OF  TUMORS  OF  BLADDER  AND  PROSTATE.  261 

duction  and  perfecting  of  this  means  of  diagnosis.  It  is  for  these 
reasons  that  attention  may  here  be  drawn  most  conveniently  to  elec- 
tric cystoscopy.  For  its  general  application  to  local  states  of  uri- 
nary disturbance  reference  should  be  made  to  special  works  upon  this 
subject,  among  which  I  may  mention  those  of  my  colleague,  Mr. 
Hurry  Fenwick,"'  as  containing  the  fullest  information,  and  as  fur- 
nishing the  most  practical  guide  to  all  matters  relating  to  it.  I  have 
already  indicated  the  symptoms  which  would  suggest  the  presence 
of  a  growth  within  the  bladder,  and  the  necessity  for  proceeding  to 
an  examination  of  this  kind. 

For  this  purpose  I  have  been  in  the  habit  of  using  Leiter's  instru- 
ments. As  a  rule  it  is  best  to  have  the  patient  placed  under  an  anaes- 
thetic, and  in  the  lithotomy  position  at  the  end  of  an  operating  table 
of  a  suitable  height.  A  deep  injection  of  a  ten-per-cent  solution  of 
cocaine  in  some  cases  suffices  to  render  the  examination  painless. 
The  following  requirements,  as  stated  by  Mr.  Fenwick,  are  necessary 
for  success :  "  (1)  The  urethral  canal  must  have  a  calibre  of  twenty- 
two  French  catheter  gauge.  (2)  The  bladder  must  have  a  capacity 
of  at  least  four  ounces.  (3)  The  water  in  the  bladder  must  be  trans- 
lucent, and  ought  to  be  perfectly  transparent."  The  last  condition  is 
probably  the  most  difficult  to  obtain  in  cases  of  growth,  and  requires 
some  patience  and  aptitude  in  the  preliminary  irrigation  of  the  blad- 
der. Washing  out  with  equal  parts  of  extract  of  witch  hazel  and 
hot  water  will  often  render  the  urine  clear  of  blood. 

The  kind  of  vesical  growth  and  the  possibility  of  its  complete  or 
partial  removal  may  in  this  way  be  determined  with  much  accuracy. 
In  some  forms  of  pendulous,  grape-like,  and  simple  papilloma  removal 
may  usually  be  undertaken  with  the  prospect  of  permanent  success, 
while  in  diffuse  villous  carcinomata  of  considerable  extent,  operative 
measures  can  do  no  more  than  palliate  symptoms  arising  from  con- 
stant hemorrhage  and  obstruction  to  micturition,  as  well  as  from  the 
tension  produced  by  the  pressure  of  the  growth  on  the  wall  of  the 
bladder.  Hence  the  growths  that  are  most  accessible  to  operative 
treatment  are  those  belonging  to  the  former  variety.  Their  diagnosis 
is  tolerably  easy ;  they  are  usually  situated  at  the  most  accessible  part 
of  the  bladder,  namely,  at  the  orifice  of  a  ureter,  and  when  removed, 
as  I  have  had  frequent  occasion  to  note,  they  do  not  recur.  On  the 
other  hand,  the  carcinomata  and  semi-malignant  growths  of  the  blad- 
der, so  far  as  their  removal  by  operation  is  concerned,  in  no  way  dif- 
fer from  what  is  observed,  in  this  respect,  in  connection  with  similar 
tumors  situated  in  other  parts  of  the  body. 

I  have  opened  the  bladder  in  some  cases  by  the  supra-pubic  and 
in  others  by  the  perineal  method,  though  the  former  is  to  be  pre- 


262  HAEEISON — DISEASES  OF  THE  BLADDER. 

ferred,  on  the  same  principle  tliat  tlie  intestine  is  sometimes  opened 
and  an  artificial  anus  formed  to  relieve  the  obstruction  and  distress 
whicli  is  occasioned  by  a  cancer  situated  lower  down  tlie  intestinal 
canal.  On  grounds  sucli  as  these,  a  supra-pubic  opening  for  drainage, 
and  as  a  substitute  for  the  long  and  narrow  channel  of  the  natural 
urethra,  is  to  be  recommended  when  the  nature  of  the  symptoms  de- 
mands it  by  reason  of  the  bladder  being  obstructed  by  a  more  or  less 
fungating  cancer.  In  the  following  case  the  relief  afforded  by  opera- 
tion was  marked  and  continuous  as  long  as  the  patient  lived : 

Case. — A  male  patient,  aged  66,  whom  I  saw  toward  the  end  of 
1892,  had  been  suffering  from  vesical  hemorrhage  for  many  months 
previously.  The  bleeding,  retention  of  urine  and  clots,  and  the  pain 
from  tension  had  become  so  constant  and  unmanageable  as  to  indicate 
the  necessity  for  adopting  other  means,  as  all  medicines  as  well  as 
catheterism  and  irrigation  of  the  bladder  had  proved  useless.  I  ad- 
vised a  supra-pubic  opening,  which  I  made  shortly  after  I  first, saw 
the  patient,  and  removed  portions  of  a  carcinomatous  growth  from  a 
hard  base  immediately  above  the  prostate.  The  relief  was  complete, 
the  growth  was  checked,  and  the  hemorrhage  was  only  slight  and  oc- 
casional. The  interior  of  the  bladder  was  rendered  clean  and  aseptic 
by  passing  a  soft  catheter  each  day  along  the  urethra  and  washing  out 
through  the  wound.  The  urine  was  discharged  hj  the  opening,  and 
the  patient  kept  dry  by  means  of  wood-wool  pads.  He  was  enabled 
to  get  about  again,  and  remained  free  from  pain  until  a  fortnight  be- 
fore his  death,  five  months  afterward. 

When  it  is  determined  to  operate  for  the  removal  of  a  tumor  within 
the  bladder,  with  the  object  of  either  cure  or  relief,  supra-pubic  cys- 
totomy, as  described  later  on,  is  on  all  grounds  to  be  recommended. 
If  the  connections  of  the  tumor  are  extensive,  and  there  is  a  doubt 
as  to  whether  aU  can  be  got  away  without  doing  serious  damage  to 
the  bladder  itseK,  I  feel  sure  that  we  had  better  content  ourselves 
with  the  opening,  which  may  under  all  circumstances  be  safely  made, 
and  the  drainage  with  a  suitable  apparatus  that  this  aperture  will 
provide.  The  lesser  proceeding  has  in  many  instances  proved  the 
means  of  arresting  hemorrhage,  and  of  adding  materially  to  the  com- 
fort as  well  as  to  the  life  of  the  patient,  even  where  it  has  been  found 
impossible  either  to  remove  the  tumor  or  with  safety  to  reduce  its 
size.  And  what  relates  to  the  male  is  equally  applicable  to  the  fe- 
male, though  with  the  latter,  by  reason  of  the  anatomical  differences 
in  the  parts,  both  exploration  and  removal  can  be  more  readily 
effected.  It  must  not  be  overlooked  that  in  some  cases  of  malignant 
tumor  of  the  bladder  which  have  been  operated  upon,  recurrence  has 
taken  place  in  the  wound.  Dr.  J.  H.  Neale  '°  records  an  instance  of 
adeno-encephaloid  cancer  of  the  bladder,  operated  on  by  Mr.  C.  H. 


TREATMENT  OE  TUMOES  OP  BLADDER  AND  PROSTATE.  263 

Marriott,  where  the  wound  and  the  perinaeum  adjoining  were  subse- 
quently largely  invaded  by  the  growth,  Mr.  Marriott  remarks: 
"  This  case  alone  appears  to  me  to  put  a  limit  to  the  range  of  surgical 
treatment  of  vesical  tumors.  Where  a  polypoid  or  pedunculated 
growth  is  diagnosed,  by  all  means  remove  it;  but  in  the  case  of  a 
sessile  tumor,  closely  incorporated  with  the  muscular  walls  of  the  blad- 
der, the  treatment  best  suited  to  the  requirements  of  the  case  seems  to 
me  to  be  to  establish  and  maintain  free  drainage  and  so  relieve  the 
strangury,  leaving  the  tumor  to  take  its  own  course."  In  this  ex- 
pression of  opinion  most  surgeons  of  experience,  I  think,  will  agree. 

Some  cases  of  partial  resection  of  the  bladder  wall  containing  a 
growth  have  been  recorded  by  Albarran  and  others,  but  this  method 
of  treatment  has  so  far  not  proved  to  be  practicable  except  to  such  a 
limited  extent  as  hardly  to  require  special  notice. 

In  malignant  growths  involving  the  bladder,  which  are  considered 
as  being  outside  the  pale  of  operative  treatment,  the  question  arises, 
can  anything  be  done  either  to  check  their  progress  or  to  avert  the 
blood  deterioration  which  becomes  evident?  For  these  purposes 
iodide  of  potassium  and  Chian  turpentine  have  sometimes  been  used 
with  apparent  temporary  advantage.  The  former  certainly  does  oc- 
casionally check  the  growth  and  extension  of  neoplasms,  while  the 
latter  has  been  known  to  do  more,  as  stated  by  the  late  Mr.  Clay,  when 
given  in  malignant  growths  involving  more  particularly  the  urinary 
passages.  The  therapeutic  effects  of  Chian  turpentine  may  possibly 
be  due  to  some  of  the  constituents  of  the  drug  being  eliminated  by 
the  urine,  and  this  may  also  explain  its  efficacy,  undoubtedly  observed 
in  some  instances,  in  controlling  hemorrhage  and  rendering  the  ab- 
sorxjtion  of  cast-off  products  of  inflammation  less  deleterious. 

3.  The  Destructive  Stage. — The  last  phase  of  malignant  growth 
within  the  bladder  may  be  the  inclusion  of  other  parts,  such  as  the 
intestines,  and  the  formation  of  a  fistulous  communication  between 
these  two  cavities.  The  symptoms  attending  such  a  termination  are 
generally  of  a  most  distressing  nature,  due  to  the  intermixture  of 
fseces  and  urine.  Though  colotomy  cannot  be  performed  for  malig- 
nant perforations  with  the  hope  of  obtaining  a  permanent  cure,  it  is 
6f  ten  to  be  recommended  as  a  means  of  arresting  pain  and  prolonging 
life. 

The  functions  of  the  bladder  may  be  seriously  interfered  with  by 
the  growth  of  tumors  having  origin  in  other  organs  or  parts,  such  as 
the  uterus  and  ovaries  in  the  female,  and  in  the  contents  of  the  pel- 
vis generally,  including  growths  springing  from  the  pelvis.  These 
occasionally  fungate  into  the  bladder  by  ulceration  through  it,  and 
thus  cause  hematuria. 


264  HAEEISON — DISEASES  OF  THE  BLADDEB. 

It  will  not  be  necessary  to  make  special  reference  to  tlie  operative 
treatment  of  tumors  of  tlie  prostate.  Most  of  these  are  inseparably 
connected  with  the  bladder,  and  but  little  can  be  done  by  operation. 
When  the  catheter  fails  to  relieve  pain  and  the  distress  and  spasm 
which  the  retention  of  urine  and  blood-clots  is  capable  of  causing,  the 
propriety  of  a  supra-pubic  or  perineal  incision  for  exploration,  drain- 
age, and,  if  found  feasible,  extirpation  of  the  part,  may  then  be  con- 
sidered. 

Endemic  Haematu^ia. 

This  term  is  applied  to  forms  of  haematuria  chiefly  met  with  in 
tropical  countries,  and  is  dependent  upon  the  presence  of  a  parasite. 
The  BilJiarzia  luematobia  was  first  discovered  in  the  portal  vessels  of 
man  in  1851,  by  Dr.  Bilharz,  of  Cairo,  after  whom  Cobbold  subse- 
quently named  the  parasite.  In  1864,  Dr.  John  Harley  discovered 
the  ova  of  the  worm  in  the  urine  of  a  patient  from  the  Cape  of  Good 
Hope.  Subsequent  investigations  have  shown  that  this  parasite  has  a 
wide  area  of  distribution  in  Africa,  where  it  affects  men  and  apes,  and, 
to  a  less  extent,  sheep  and  oxen.  The  diseases  of  man  dependent  on 
its  presence  are  a  certain  proportion  of  the  cases  of  chronic  endemic 
Egyptian  dysentery,  the  majority  of  cases  of  endemic  hsematuria  of 
Egypt,  Natal,  and  the  Cape,  and  also,  in  all  probability,  the  endemic 
hsematuria  of  the  Mauritius. 

This  parasite  is  a  unisexual  trematode  worm ;  the  male,  about  half 
an  inch  in  length  and  rather  flattened,  acquires  a  cylindrical  appear- 
ance from  the  thinned  lateral  margins  of  the  body  being  infolded  ven- 
trally  so  as  to  overlap  and  form  a  sort  of  channel  (the  gynsecophoric 
canal)  for  the  reception  of  the  female  during  and  after  copulation. 
The  female  is  longer  and  thinner  than  the  male,  and  quite  cylindrical. 
The  eggs  are  oval,  about  TeTr^h  of  an  inch  in  length,  and  pointed  at 
one  end,  which  is  armed  with  a  short,  sharp,  spine  terminal  in  posi- 
tion when  the  ova  are  lodged  in  the  urinary  passages,  but  lateral  when 
they  lie  in  the  mucosa  of  the  bowel  (Zancarol) .  The  outer  layer  of 
the  ovum  is  a  tough,  hard  shell  of  keratin ;  inside  this  the  yolk  seg- 
ments and  develops  into  a  ciliated  embryo,  the  shell  is  ruptured,  and 
the  now  free  swimming  ciliated  trematode  probably  passes  into  the 
body  of  some  intermediate  host  belonging  to  the  snail  tribe,  where  it 
changes  into  a  cercaria,  to  be  subsequently  again  acquired  by  man 
through  the  medium  of  stagnant  drinking-water.  The  cercaria  stage 
and  its  host  are  unknown. 

I  am  indebted  to  Sir  W.  Boberts  for  the  plate  illustrating  bilharzia 
in  urine  from  a  case  which  he  had  an  opportunity  of  seeing  in  the 
Manchester  Infirmary  (Fig.  48).     The  patient  was  a  groom,  aged  nine- 


ENDEMIC  HEMATURIA. 


265 


teen,  in  tlie  service  of  the  Viceroy  of  Egypt,  and  had  been  in  the  habit 
of  drinking  unfiltered  Nile  water,  and  of  eating  watercress  freely. 

In  man,  the  adult  male  and  female  worms  reside,  in  a  few  cases, 
in  the  vena  cava  inferior  and  its  tributaries,  but  the  true  home  of  the 


Fig.  48. — Bilharzia  in  Urine.  1.  Free  embryos,  showing  the  different  shapes  they  assume  as 
they  swim  about  in  the  urine.  2.  Ova  containing  unhatehed  embryos.  3.  Empty  shells  from 
which  the  ova  have  escaped. 


parasite  is  in  the  portal  vein  and  its  numerous  tributaries.  Kartalis 
has  counted  three  hundred,  mostly  in  sexual  pairs,  in  the  portal  sys- 
tem of  a  single  case.  The  parasites,  after  impregnation,  are  to  be 
found  in  largest  numbers  in  the  submucosa  of  the  bladder,  ureter, 
renal  pelvis,  and  rectum.  Here,  lying  in  large  smooth-walled  spaces, 
which  are  dilated  blood-vessels,  the  female  deposits  her  eggs,  which 
pass  on  to  the  surface  of  the  mucosa,  possibly  by  the  boring  action  of 
their  spines,  assisted  materially,  in  the  case  of  the  bladder,  by  the 
contraction  of  that  viscus.  As  they  become  free,  the  surface  of  the 
mucosa  is  lacerated,  and  blood  escapes  freely  from  the  torn  capillaries 
and  is  discharged  with  the  ova  and  urine.  Although  empty  shells 
have  been  found  in  the  left  heart,  and  many  ova  in  the  lungs  and 
liver  of  some  cases,  by  Dr.  Mackie,  of  Alexandria,  still  the  Bilharzia 
infarcta  of  Sonsino  do  not  appear  to  be  of  frequent  occurrence  except 
in  the  neighborhood  of  the  living  parasite ;  the  position  of  the  pa- 
rents xjre vents  the  ova  from  making  their  way  into  the  larger  veins, 
and  acts  as  a  block  to  direct  them  toward  the  anastomosing  capilla- 
ries, which,  from  their  size,  they  cannot  pass  along. 

When  bilharzia  are  lodged  in  the  veins  of  the  urinary  apparatus, ' 
they  produce  symi)toms  varying  according  to  their  number  and  posi- 
tion.    In  Natal,  especially,  many  boys  harbor  the  parasite  without 


266  HAERISON — ^DISEASES   OF  THE   BLADDER. 

mucli  inconvenience ;  their  general  health  is  usually  good ;  they  have 
occasional  attacks  of  lassitude,  with  pain  in  the  loins  or  perineeum, 
generally  after  exertion,  and  they  have  intermittent  hsematuria,  of 
which,  however,  they  take  but  little  notice,  as  it  mostly  disappears 
before  puberty.  The  ova  may,  as  Dr.  Harley  has  pointed  out,  be 
still  present  in  the  urine  when  all  other  signs  of  existence  of  the  para- 
site have  disappeared.  In  more  serious  cases  the  symptoms  are,  in 
addition  to  those  already  named,  the  presence  of  muco-pus  along  with 
the  ova  and  blood  in  the  urine,  frequent  micturition,  vesical  tenesmus, 
and  all  the  signs  of  chronic  cystitis.  The  blood  is  usually  passed 
almost  pure  at  the  end  of  micturition,  and  nearly  always  contains 
many  ova.  Post  mortem  or  after  a  cystotomy,  the  mucous  membrane 
is  found  to  be  swollen  and  ecchyniosed  in  patches,  usually  on  the 
posterior  wall  of  the  bladder,  or  showing  here  and  there  elevated 
thickenings,  covered  with  a  gritty  material,  composed  partly  of  urates 
or  uric  acid,  and  partly  of  ova.  In  the  interior  of  the  thickenings  are 
many  yellowish-white  specks,  made  up  entirely  of  ova,  lying  in 
dilated  vascular  spaces.  In  other  cases,  where  death  has  resulted 
from  exhaustion  or  the  supervention  of  typhoid  symptoms,  the  bladder 
is  small  and  contracted,  its  muscular  wall  greatly  thickened,  and  the 
mucosa  and  submucosa  involved  in  large,  irregular,  elevated  lumps, 
with  shreddy  surfaces,  lying  •  mainly  at  the  base  and  around  the 
urethral  orifice  and  constituting  a  veritable  tumor  of  the  bladder.  It 
would  appear  (Bilharz  and  Meckel)  that  sixty-three  per  cent  of  the 
Egyptian  fellaheen  are  infested  with  bilharzia. 

A  case  which  I  saw  in  the  Liverpool  Royal  Infirmary  under  the  care 
of  Dr.  Davidson,  and  which  seemed  at  first  sight  to  be  one  of  in- 
termittent hsemoglobinuria,  disclosed,  on  further  investigation,  the 
occasional  presence  in  the  blood-stained  urine  of  ova  closely  resem- 
bling, if  not  identical  with,  those  of  bilharzia.  The  patient  a  man 
aged  about  forty,  was  a  native  of  the  Scottish  highlands,  and  had 
never  been  abroad. 

When  the  vessels  of  the  ureter  or  renal  pelvis  are  the  habitat  of  the 
parasite,  the  results  are  usually  more  rapidly  fatal,  from  the  produc- 
tion of  hydronephrosis,  of  pyelonephritis,  or  of  acute  suppuration 
of  the  kidneys.  Obstruction  of  the  vesical  orifice  of  one  or  both 
ureters  occasionally  takes  place  from  their  involvement  in  the  bladder 
tumors,  and  hydronephrosis  or  pyelonephritis  may  result.  Males 
are  much  more  liable  to  the  disease  than  females.  Provided  the 
patient  can  be  kept  alive  and  free  from  reinfection,  the  disease  must 
evidently  have  a  self-limited  duration,  dependent  on  the  natural  period 
of  life  of  the  parasite.  This  is  not  yet  very  definitely  ascertained, 
but  appears  to  vary  from  one  or  two  to  ten  years.     It  is  to  be  noted 


ENDEMIC  H^MATUEIA.  '  267 

ttat  the  eggs  of  bilharzia  often  form  the  nuclei  of  uric  acid  calculi, 
which  may  not  give  rise  to  symptoms  of  their  presence  until  some  years 
after  all  indications  of  the  parasitic  disease  have  disappeared." 

As  bearing  upon  the  clinical  features  and  surgical  treatment  of  this 
disease,  I  will  quote  the  following  remarks  by  Dr.  Mackie  relative  to 
a  specimen  he  forwarded  me,  which  was  shown  at  the  Pathological 
Society  of  London  by  Mr.  Butlin."  It  is  now  preserved  in  the  mu- 
seum of  St.  Bartholomew's  Hospital.     Dr.  Mackie  thus  describes  it: 

"  Specimen  of  diseased  bladder,  kidneys,  rectum,  and  dilated  and 
thickened  ureters,  from  a  fatal  case  of  severe  hsematuria  from  bil- 
harzia hsematobia.  The  old  man  came  under  my  care  suffering  from 
dreadful  continued  pains,  and  passing  almost  pure  blood  mixed  with 
enormous  quantities  of  debris  containing  ova  of  bilharzia.  To  ease  the 
pain  and  examine  his  bladder,  to  see  if  the  surface  could  be  scraped  or 
any  tumor  removed,  I  performed  perineal  urethrotomy.  The  bladder 
was  found  to  be  studded  full  of  papillomatous-feeling  tumors,-  bleeding 
freely.  It  was  no  use  trying  to  remove  any,  as  they  were  in  dozens. 
So  nothing  further  was  done.  The  pain  was  eased,  the  hgematuria  di- 
minished, but  he  died  of  uraemia  a  week  afterward.  Post-mortem  ex- 
amination showed  that  the  walls  of  the  bladder  were  full  of  small  tumors 
filled  with  ova."  To  another  specimen  of  the  same  kind  of  disease. 
Dr.  Mackie  refers  in  the  following  words :  "  This  specimen  is  from 
a  man  who  came  to  hospital  for  hsematuria,  passing  blood  and  debris, 
with  pus  and  mucus,  suffering  agony.  I  performed  perineal  ure- 
throtomy, and  drained  the  bladder,  which,  as  usual,  stopped  the  hem- 
orrhage ;  but  he  died  about  a  fortnight  after  of  rupture  of  the  bladder 
from  destruction  of  the  walls  by  ulceration  caused  by  bilharzia."  Dr. 
Mackie  goes  on  to  remark :  "  For  some  years  I  have  been  directing  my 
attention  to  this  disease  in  connection  with  urinary  fistula,  which  is 
nearly  as  common  as  hsematuria,  and  which  I  have  proved  to  my  sat- 
isfaction is  caused  by  the  same  parasite,  as  in  every  case  I  find  the 
ova  in  hundreds  in  the  hard  tissue  around  the  fistulous  tracks  in  the 
perineum.  In  every  case  there  is  hsematuria  with  ova  in  the  bladder 
with  a  history  of  sudden  phlegmon  and  perineal  abscess,  with  no  his- 
tory of  injury,  or  stricture,  or  gonorrhoea,  or  anything  urethral  to  ac- 
count for  it.  For  a  long  time  these  cases  of  perineal  urinary  fistulse 
I)uzzled  me ;  men  came  in  with  their  perinseums  a  large  fibrous  mass, 
riddled  with  sinuses  and  fistulse,  through  which  the  urine  passed  on 
micturition ;  but  no  stricture,  their  urethra  admitting  easily  the  larg- 
est catheter,  or,  as  often  remarked  to  strangers,  I  believe  their  urethra 
would  take  in  my  little  finger,  and  no  history  of  previous  stricture." 

Various  suggestions  have  been  made  relative  to  treatment,  their  ob- 
ject being  to  effect  the  destruction  of  the  parasite  in  the  blood.    Har- 


268  HAEKISON — ^DISEASES  OP  THE  BLADDER. 

ley  recommends  tlie  administration  of  tlie  oil  of  turpentine  and  of 
male  fern,  with  a  little  cliloroform,  in  order  to  expel  the  ova  from  the 
urinary  passages,  and  a  solution  of  bicarbonate  of  potassium  to  relieve 
renal  irritation.  Dr.  Fonguet "  also  advocates  the  use  of  male  fern, 
observing  that  "  the  blood  disappears  from  the  urine  after  a  few  days' 
treatment.  I  employ  the  capsules  of  the  ethereal  extract  of  male  fern, 
taking  care  to  administer  the  medicine  one  hour  before  meals."  For 
a  similar  purpose  I  believe  the  iodide  of  potassium,  in  twenty-grain 
doses,  has  been  given. 

Though  I  have  no  personal  experience  in  the  treatment  of  this 
affection,  I  should  feel  disposed  to  try,  where  the  bladder  was  in- 
volved, a  solution  of  corrosive  sublimate  as  a  wash  (1  in  10,000) ;  its 
use  as  a  bactericide  holds  out  some  hope  that  it  might  be  serviceable 
in  the  destruction  of  this  parasite.  Wliere  perineal  section  is  em- 
ployed, as  illustrated  in  the  cases  referred  to,  for  the  purpose  of 
clearing  the  bladder  of  the  excrescences  formed  within  its  interior  by 
these  parasites  and  their  ova,  irrigation  with  a  suitable  solution  of 
corrosive  sublimate  seems  worthy  of  trial. 

This  disease,  though  chiefly  affecting  the  urinary  apparatus,  is  not 
limited  to  it,  but  frequently  involves  the  intestinal  canal,  producing 
symptoms  simulating  dysentery  and  disease  of  the  lower  bowel. 
Among  the  specimens  which  have  been  forwarded  to  me  for  examination 
is  a  polypoid  parasitic  excrescence  in  reference  to  which  Dr.  Mackie 
states :  "  This  is  a  tumor  removed  by  the  ecraseur  from  about  four 
inches  up  the  rectum  of  a  man  who  came  to  me  complaining  of  dysen- 
tery and  prolapse  of  the  bowel ;  he  is  now  about,  the  dysentery  and  pro- 
lapse having  disappeared  since  the  operation.  The  man  had  also  ova  in 
his  urine,  but  passed  only  a  drop  of  blood  at  the  end  of  micturition." 

When  we  consider  the  serious  injury  which  is  done  to  native  popu- 
lations by  this  disease,  in  addition  to  the  risk  of  contracting  and 
spreading  it  that  is  incurred  by  troops  and  others  visiting  these  dis- 
tricts, the  importance  of  a  more  thorough  knowledge  of  it,  in  relation 
to  its  prevention  and  treatment,  must  be  admitted. 

From  an  examination  of  numerous  specimens  it  is  found  that  car- 
cinoma often  occurs  with  bilharzia  as  a  complication.  Prolonged 
investigations  in  places  where  such  cases  are  common,  relative  to  the 
frequency  with  which  bilharzia,  cancer,  and  calculus  coexist,  and  the 
order  of  their  appearance,  would  be  of  value  in  reference  to  certain 
points  in  the  natural  history  and  pathology  of  these  three  affections. 
Whether  the  parasite  merely  plays  the  part  of  an  irritant  in  a  person 
in  some  way  predisposed  to  generate  cancer,  or  whether  the  relation- 
ship between  the  parasite  and  the  proliferous  tissue  growths  which 
we  are  accustomed  to  speak  of  as  cancer  is  even  more  connected  and 


SINUSES   CONNECTED  WITH  THE  BLADDER.  269 

intimate,  are  points  among  others  whicli  naturally  become  prominent 
in  connection  with  the  pathology  of  this  disease. 

SINUSES   CONNECTED  WITH  THE  BLADDER. 

Under  this  heading  will  be  considered  a  variety  of  cases  where 
sinuses  have  formed  in  connection  with  the  bladder,  but  not  neces- 
sarily in  consequence  of  urethral  stricture. 

Looking  over  these  cases  of  sinus  or  fistula,  they  will  permit  of 
being  grouped  in  the  following  way : 

(1)  Those  between  the  bladder  and  the  intestines.  (2)  In  the  su- 
pra-pubic region  leading  to  the  bladder ;  (a)  Arising  from  abscesses, 
(&)  Arising  from  supra-pubic  punctures  or  incisions.  (3)  Con- 
nected with  the  bladder,  but  opening  externally  in  other  directions 
than  in  the  preceding.  (4)  Between  the  bladder  and  vagina  (vesico- 
vaginal fistulse).  (5)  Leading  from  the  bladder  into  the  rectum 
through  the  prostate  or  trigone;  (a)  Consequent  on  prostatic  ab- 
scess, (b)  Following  puncture  of  the  bladder  from  the  rectum,  or 
other  similar  procedure. 

Class  1. — Fistulous  communications  between  the  bladder  and  in- 
testines of  a  non-malignant  character  may  be  caused  in  three  ways : 

(a)  By  the  passage  of  foreign  bodies  from  the  intestines  into  the 
bladder ;  these  have  been  referred  to  in  a  previous  section. 

(6)  By  various  kinds  of  non-malignant  ulcerations,  such  as  tuber- 
cular or  dysenteric,  proceeding  from  the  intestine  into  the  bladder, 
and,  more  rarely,  from  the  bladder  toward  the  intestines. 

(c)  By  abscesses  in  relation  with  the  abdominal  viscera. 

Non-malignant  sinuses  between  the  bowels  and  bladder  vary  much 
in  degree,  and  these  differences  will,  to  a  certain  extent,  serve  as  in- 
dications for  treatment.  The  symptoms  are  usually  these :  more  or 
less  faeces  and  flatus  find  their  way  into  the  bladder,  and  if  the  sinus  is 
sufficiently  low  down,  as  in  the  sigmoid  flexure  or  rectum,  urine  may 
be  passed  in  considerable  quantities,  either  pure  or  mixed  with  faeces, 
by  the  anus.  As  a  rule,  these  symptoms  are  the  more  marked  when 
there  is  diarrhoea  or  flatulent  dyspepsia ;  in  fact  some  persons  only 
suffer  when  the  bowels  are  much  disturbed.  One  patient  describes 
his  consciousness  of  the  passage  of  air  from  the  bladder  when  mictu- 
rition closes  with  a  slight  fizzing  sound,  such  as  a  soda-water  bottle 
gives  off.  In  another  instance,  the  entrance  Of  air  into  the  bladder 
sometimes  occasions  an  acute  attack  of  vesical  colic;  and  cases  are 
recorded  where  intestinal  worms  have  thus  entered  the  bladder.  In 
the  following  extract.  Dr.  W.  D.  Kingdon,  of  Exeter,  sums  up  the 
particulars  of  a  case  which  was  reported  and  illustrated  :'^ 


270  HAEEISON — DISEASES  OP  THE  BLADDER. 

Case. — Tlie  calculus  on  being  caiefuUy  divided  displayed  in 
its  centre  a  large  pin,  ts^hich.  satisfactorily  accounts  for  tlie  singular 
appearances  detailed.  The  poor  boy  must  have  swallowed  the  pin, 
which,  after  traversing  the  small  intestines,  formed  a  lodgment  in  the 
appendix  vermiformis ;  here  the  irritation  caused  by  it  must  have  given 
rise  to  inflammation  and  adhesion  of  the  process  to  the  exterior  of  the 
bladder,  and  subsequently  by  ulceration  to  the  passage  of  the  pin  into 
the  urinary  bladder,  where  it  formed  the  nucleus  of  a  calculus  discov- 
ered after  death,  though  not  detected  during  life.  The  fistulous  com- 
munication with  the  bladder  will  likewise  account  for  the  voiding  of 
the  urine  from  the  anus,  the  natural  orifice  being  closed  by  the  calcu- 
lus ;  and  also  for  the  passing  of  the  worms  through  the  urethra  on  the 
several  occasions  mentioned. 

The  following  illustrations  are  selected  from  a  communication  I 
made  upon  the  subject : "^ 

Case  I. — A  man,  aged  58.  Ten  years  before  I  saw  him  he  was  laid 
up  for  some  weeks  with  acute  pain  in  the  lumbar  region,  which  re- 
sulted in  the  discharge  of  pus  into  the  bladder  and  its  escape  with  the 
urine.  On  the  sudden  appearance  of  purulent  urine  the  pain  in  the 
back  ceased  and  he  rapidly  convalesced.  On  going  about  again,  after 
this  attack,  he  noticed  the  sputtering  of  air  at  the  close  of  micturition, 
and  this  has  recurred  at  times  ever  since,  but  has  caused  him  no 
further  inconvenience.  The  symjjtom  about  which  I  was  consulted 
was  the  occasional  discharge  of  a  colorless  fluid  from  the  rectum  inde- 
pendently of  defecation.  I  did  not  see  any  of  the  fluid,  but  it  was 
sufficient  when  it  occurred  to  moisten  the  linen,  and  thus  to  make  the 
patient  uncomfortable.  On  examination  of  the  rectum  with  the  finger 
and  speculum,  I  could  not  detect  anything  abnormal  except  a  little 
irregular  enlargement  of  the  prostate,  but  not  such  as  is  usually  met 
with  in  ordinary  hypertrophy  of  this  part.  The  urine  was  normal  in 
composition,  but  there  was  a  slight  deposit  which  microscopic  exam- 
ination showed  to  contain  elements  of  muscular  tissue  and  vegetable 
fibre. 

Case  II. — I  saw  a  man  in  1887,  aged  50,  who  two  years  previously 
suffered  from  some  obscure  abdominal  symptoms  in  the  region  of  the 
bladder,  attended  \nt\i  acute  pain,  since  which  he  had  noticed  fecu- 
lent matter  in  the  urine  and  the  discharge  of  air  at  the  close  of  mic- 
turition. Examination  of  the  rectum  disclosed  nothing  worthy  of 
note  further  than  that  I  was  able  by  pressing  on  the  prostate  and  ijos- 
terior  wall  of  the  bladder  to  make  urine  mixed  with  feculent  matter 
exude  from  the  orifice  of  the  penis.  In  aU  other  respects  this  patient 
seemed  to  enjoy  excellent  health,  and  there  was  no  evidence  pointing 
to  malignancy.  I  have  seen  him  on  two  or  three  occasions  since  in 
consequence  of  his  suffering  from  an  acute  paroxysm  of  pain  over  the 
region  of  the  bladder.  Each  time  I  found  the  pain  was  due  to  the 
blocking  of  the  prostatic  urethra  with  a  hardened  nodule  of  faeces  and 
the  rapid  distention  of  the  bladder  with  air.  Immediate  relief  was 
given  by  passing  a  catheter,  which  afforded  vent  to  some  feculent 
urine  and  a  large  amount  of  pent-up  gas.  This  patient's  symptoms 
were  always  intensified  when  diarrhoea  was  present.     Though  much 


SINUSES    CONNECTED  WITH  THE  BLADDER.  271 

annoyed  at  times  by  these  local  symptoms,  lie  continues,  I  under- 
stand, to  enjoy  good  health  and  to  lead  an  active  life. 

Case  III. — A  man,  aged  about  60.  His  last  illness  commenced  a 
short  time  before  I  saw  him,  with  intense  pain  down  the  course  of  the 
right  sciatic  nerve,  which  lasted  for  rather  more  than  a  week ;  then 
retention  of  urine  supervened  from  enlarged  prostate,  in  addition  to 
some  urethral  stricture  which  necessitated  daily  catheterism.  In  the 
course  of  a  few  days  the  pain  in  the  back  and  leg  entirely  ceased, 
coincident  with  the  appearance  of  pus  in  considerable  quantity  in  the 
urine.  The  urine  as  soon  as  it  became  jjurulent  was  rendered  most 
offensive,  in  spite  of  the  bladder  being  washed  out  with  disinfectants. 
He  appears  to  have  experienced  some  difficulty  in  urinating  for  several 
years,  a  circumstance  which  was  probably  due  to  the  stricture  in  the 
urethra.  He  had  not  lost  flesh  and  there  was  no  evidence  of  malig- 
nant disease.  The  urine  continued  to  be  horribly  offensive,  as  large 
quantities  of  gas  and  fseces  were  constantly  mixed  and  discharged 
with  it  in  spite  of  all  the  means  that  were  used.  He  remained  much 
in  this  way  for  about  two  months  after  I  first  saw  him,  and  then  lapsed 
into  a  comatose  state,  from  which  he  never  rallied.  He  was  unwill- 
ing to  submit  to  such  operative  measures  as  were  proposed  for  his 
relief.  The  patient  stated  that  when  he  was  about  20  years  of  age  he 
suffered  from  an  abdominal  abscess'  of  some  kind,  when  it  was  be- 
lieved that  a  communication  had  taken  place  between  the  bladder  and 
intestines,  as  j)us,  and  what  he  thought  was  feculent  matter  had  been 
at  times  discharged  with  the  urine,  but  never  sufficiently  to  cause  him, 
inconvenience.  He  had  occasionally  passed  air  at  the  close  of  mic- 
turition, which  he  likened  to  the  expiring  efforts  of  a  siphon  soda- 
water  bottle.  In  all  other  respects  he  appears  to  have  enjoyed  good 
health.  His  urine  was  on  several  occasions  examined  for  me  by  Sir 
William  Roberts,  and  showed  unmistakable  evidence  of  intestinal 
contamination.  The  autoj)sy  showed  an  opening  near  the  top  of  the 
bladder,  looking  as  though  it  had  alway;  existed,  lined  with  mucous 
membrane,  not  patent  but  contracted,  and  resembling  a  miniature  anus. 
No.  8  catheter  passed  easily  through  it  into  a  cavity  surrounding  the 
descending  colon,  and  formed  by  adhesions  to  the  adjacent  parts, 
which  were  with  difficulty  separated.  This  space  contained  no  fecal 
matter,  but  was  rough  from  inflammatory  products,  and  communi- 
cated by  several  openings  with  the  intestine.  The  colon  took  an  un- 
usual course ;  instead  of  passing  down  into  the  left  loin,  it  curved 
across  the  lower  part  of  the  abdomen  in  front  of  the  small  intestines, 
and  disappeared  a  little  to  the  right  side  and  under  the  bladder  to  its 
termination  in  the  anus. 

In  reviewing  cases  of  this  kind,  more  particularly  in  reference  to 
the  question  of  treatment,  we  can  divide  them  into  two  classes: 
(1)  those  where  the  inconvenience  resulting  is  so  slight  as  would 
hardly  warrant  the  adoption  of  any  important  surgical  interference ; 
and  (2)  those  where  the  inconvenience  is  an  increasing  one,  either  by 
a  gradual  process  or  by  the  intercurrence  of  acute  symptoms,  or 
where  the  condition  of  the  bladder  by  decomposition  of  the  urine  be- 


272  HAEEISON — DISEASES   OF  THE  BLADDER. 

comes  such  as  seriously  to  jeopardize  the  health  of  other  parts  of  the 
urinary  apparatus,  especially  the  kidneys.  I  think  it  will  be  found 
that  the  cases  quoted  illustrate  in  some  degree  these  deductions. 

In  reference  to  the  first  variety,  there  can  be  no  doubt  that  persons 
live  for  many  years  and  enjoy  good  health  who  are  liable  to  the  es- 
cape of  gas  and  faeces  in  this  way.  I  have  had  the  opportunity  of  ex- 
amining some  of  those  cases  which  have  been  described  under  the 
term  pneumaturia,  implying  that  the  urine  or  other  secretion  con- 
nected with  the  urinary  apparatus  had  undergone  some  form  of  change 
by  which  gas  was  evolved,  and  either  expelled  or  temporarily  re- 
tained. I  have  no  hesitation  in  stating  that  they  were  all  instances 
of  vesico-intestinal  fistula.  It  has  been  urged  that  air  is  met  with 
in  the  urine  in  certain  cases  of  glycosuria,  and  Dr.  Guiard  proposed 
the  term  "diabetic  pneumaturia.""  I  am  not  aware,  however,  that 
this  observation  has  been  confirmed.  Gas  in  the  urine  may  some- 
times be  caused  in  this  way :  An  alkaline  urine  such  as  that  secreted 
after  breakfast  is  allowed  to  accumulate  for  five  or  six  hours ;  then  a 
discharge  from  the  kidneys  of  a  highly  acid  urine  takes  place,  the 
resultant  chemical  action  causing  the  production  of  carbonic  acid  in 
excess  of  what  can  be  absorbed.  Cases  where  the  communication 
between  the  bowels  and  the  bladder  is  evidently  small  and  is  not  in- 
creasing, may  be  kept  in  good  health  by  careful  attention  to  digestible 
diet,  and  by  restraining  a  tendency  to  diarrhoea,  which  invariably 
aggravates  any  special  symptoms  they  may  present. 

Passing  to  the  second  class  of  cases,  where  the  communication  be- 
comes gradually  or  suddenly  enlarged,  or  where  the  urine  is  rendered 
so  foul  as  to  jeopardize  the  kidneys  as  well  as  other  portions  of  the 
urinary  tract,  it  is  clear  that  some  mechanical  expedient  in  the 
shape  of  an  operation  must  be  considered.  To  effect  any  permanent 
good  imder  such  circumstances,  it  is  obvious  that  the  flow  of  faeces 
into  the  bladder  should  be  prevented  by  causing  them  to  escape  by 
an  artificial  opening  above  the  point  where  they  are  poured  into  the 
bladder,  and  thus  to  give  the  false  passage  a  chance  of  contracting 
and  closing.  This  is  a  proposition  which,  on  paper,  is  an  easy  one 
to  make,  but  in  practice  may  be  a  difficult  one  to  decide  upon.  It 
must  not  be  overlooked  that  in  many  cases  of  vesico-intestinal  fistula 
which  appear  to  have  taken  their  origin  in  an  inflammatory  condition, 
the  viscus  involved  with  the  bladder  was  some  portion  of  the  small 
intestine.  Taking,  however,  everything  into  consideration  and  the 
probability  of  our  being  able  to  distinguish  when  the  latter  is  impli- 
cated, on  the  necessity  arising,  it  is  the  safest  practice  to  make  the 
opening  as  high  up  in  the  large  bowel  as  possible,  and  this  will  lead 
to  the  selection  of  some  portion  of  the  right  ascending  colon.     In  the 


SINUSES  CONNECTED  WITH  THE   BLADDER.  273 

third  of  the  above  related  cases  I  was  much  disposed,  considering 
the  condition  of  the  patient,  the  state  of  his  bladder,  and  the  uncer- 
tainty as  to  where  the  false  opening  was,  to  give  that  immediate  and 
safe  relief  which  a  supra-pubic  opening  could  have  afforded,  and  be 
guided  as  to  the  future  by  what  this  would  have  enabled  the  eye  as 
well  as  the  finger  to  discover. 

I  assisted  Mr.  Hakes,  in  1869,  to  operate  on  a  case  of  vesico-in- 
testinal  fistula  by  colotomy  where  the  patient  lived  for  five  years  and 
returned  to  his  employment,  subsequently  dying  of  renal  disease. 
I  refer  to  it  particularly,  as  opportunities  of  making  an  examination  of 
the  parts  at  a  considerable  interval  of  time  after  the  operation  are  not 
very  frequent." 

Case. — The  patient,  a  man,  aged  20,  with  no  history  of  syphilis, 
was  admitted  into  the  Liverpool  Eoyal  Infirmary  in  1869  suffering 
from  the  passage  of  faeces  and  flatus  into  his  bladder.  He  was  in  a 
very  miserable  condition.  He  appears  to  have  had  some  history  of 
difficulty  in  passing  his  motions  for  three  years  previously.  The 
rectum  was  unhealthy  from  ulceration,  and  a  sound  could  be  passed 
from  the  bladder  into  the  bowel.  Left  lumbar  colotomy  was  per- 
formed, and  the  patient  made  a  good  recovery.  He  resumed  his  em- 
ployment as  a  bus  conductor,  and  for  over  three  years  enjoyed  perfect 
health  and  suffered  but  little  inconvenience  from  his  artificial  anus. 
Then  he  appears  to  have  fallen  ill,  and  was  readmitted  into  the  Li- 
firmary  in  1874,  where  he  shortly  afterward  died  from  renal  disease. 
He  never  had  any  return  of  his  vesico-intestinal  fistula.  The  post- 
mortem examination  was  made  by  the  late  Dr.  Michael  Harris,  who 
attached  a  drawing  of  the  part  to  the  published  records  of  the  case. 
It  is  sufficient  here  to  state  that  the  colon  from  the  artificial  anus  to 
the  bladder  was  obliterated  and  converted  into  a  coil  of  fat :  the  fis- 
tulous opening  from  the  rectum  into  the  bladder  was  also  soundly 
closed,  nothing  but  some  old  cicatricial  tissue  remaining.  The  pa- 
tient died  from  ursemia  as  a  result  of  degeneration  of  the  kidneys.  No 
further  light  was  thrown  on  the  nature  of  the  old  ulceration  by  which 
the  bladder  and  bowel  had  been  made  to  communicate  other  than  to 
demonstrate  its  non-malignancy. 

It  should  be  remembered  that  when  the  communication  with  the 
bowel  is  in  the  small  intestine,  as  is  usually  the  case,  neither  the  air 
emitted  with  the  urine  nor  the  products  of  digestion  entering  the 
bladder  are  necessarily  either  tainted  with  the  odor  of  fseces  or  have 
their  appearance,  as  the  case  may  be.  With  the  cystoscope,  in  a  clear 
medium  it  is  quite  possible  to  see  bubbles  of  air  emerging  from  the 
orifice  of  the  false  route  and  entering  the  bladder. 

Wlienever   there  are  signs  of  fseces  entering  the  bladder,    care 

should  be  taken  that  washing  out  the  viscus  is  employed,  otherwise 

a  concretion  may  be  formed,  as  in  a  case  recorded  by  the  late  Mr. 

Charles  Hawkins.'" 
Vol.  I.— 18 


274  HAEEISON — DISEASES  OF  THE  BLADDER. 

Ulcerations  proceeding  from  the  bladder  toward  the  intestines 
are  mucli  less  common  than  the  preceding,  and  are  liable  to  be  fol- 
lowed by  fatal  results  before  the  communication  has  had  time  to  as- 
sume the  characteristics  of  a  chronic  sinus.  Belonging  to  this  class 
is  the  case  recorded  by  the  late  Mr.  T.  H.  Bartleet,  of  Birmingham, 
where  a  perforating  ulcer  of  the  bladder  made  its  way  into  the  ileum 
and  caused  death,  as  it  were  accidentally,  by  setting  up  peritonitis." 
The  ulcer,  while  confined  to  the  bladder,  appears  to  have  gone 
through  all  its  stages  without  presenting  any  symptoms,  and  while 
the  patient  continued  to  follow  his  accustomed  occupation.  A  sudden 
lifting  movement,  which  occasioned  acute  pain,  probably  broke  down 
a  recent  adhesion  between  the  bladder  and  bowel,  and  led  to  extrava- 
sation of  urine,  which  caused  death. 

Class  2. — Sinuses  in  the  supra-pubic  region  leading  into  the  blad- 
der. These  are  of  two  kinds — («)  arising  from  abscess;  (6)  from 
wounds,  surgical  or  otherwise.  Abscesses  in  the  supra-pubic  region 
may  be  confined  in  the  space  known  as  the  porta  vesicce,  and  eventually 
open  both  into  the  bladder  and  externally,  though  they  are  apt  to 
burrow  considerably,  and  thus  prove  difficult  to  heal.  Sometimes 
they  are  connected  with  caries  of  the  pubic  arch,  or  with  disease  of 
the  symphysis.  In  the  following  case  the  course  and  treatment  of 
these  abscesses  are  illustrated : 

Case. — In  1885  I  saw,  with  Dr.  H.  "W".  Knowles,  a  woman  aged 
about  20,  under  the  following  circumstances:  Fifteen  months  pre- 
viously she  had  some  swelling  and  pain  about  the  left  groin.  Three 
months  before  I  saw  her  an  abscess  formed  above  the  pubes,  which 
was  opened  externally,  and  found  to  communicate  with  the  bladder. 
A  sinus  formed,  which  resisted  all  efforts  to  close  it,  including  con- 
tinual catheterism.  Wlien  we  saw  her,  the  abdominal  parietes  were 
undermined,  and  urine  welled  up  through  the  opening  when  the  ca- 
theter was  removed.  It  was  advised  that  the  sinuses  should  be  opened 
up  and  the  catheter  again  worn.  This  was  followed  with  improve- 
ment, but  when  the  catheter  was  removed  urine  still  escaped  by  the 
wound.  Then  we  found,  on  further  examination,  that  the  urine  had 
burrowed  under  the  attachment  of  the  left  rectus  muscle.  This  we 
divided  close  to  the  pubes,  when  the  wound  soundly  healed. 

Wounds  and  punctures  made  into  the  male  bladder  above  the 
pubes,  either  accidentally  or  for  surgical  purposes,  usually  heal  when 
there  is  nothing  in  the  condition  of  the  prostate  or  urethra  to  inter- 
fere with  the  escape  of  urine  by  the  natural  passage,  though  they  are 
sometimes  tedious.  Where  there  is  a  urethral  stricture  this  must 
first  be  treated.  A  discharge  of  urine  from  the  umbilicus,  due  to  a 
congenitally  unobliterated  urachus,  is  occasionally  met  with.  If 
there  is  any  obstruction  in  front,  such  as  a  phimosis,  or  a  contraction 


SINTSES  CONKECTED  WITH  THE  BLADDER.  275 

in  the  urethra,  this  should  be  removed,  and  then  an  endeavor  may  be 
made  to  close  the  sinus  by  cauterization,  or  a  plastic  oijeration  may 
be  attempted,  as  already  mentioned. 

Class  3. — Sinuses  connected  with  the  bladder  opening  externally  in 
other  directions  than  those  specified.  These  sometimes  take  long  and 
tortuous  courses.  In  a  case  where  Mr.  Bickersteth  had  successfully 
removed,  at  the  Liverpool  Royal  Infirmary,  a  large  oxalate  stone  by 
the  supra-pubic  operation  over  twenty  years  ago,  the  only  jjrominent 
symptom  was  a  sinus  discharging  urine  which  ox)ened  near  the  great 
trochanter.  Some  remarkable  instances  are  recorded,  chiefly  in  the 
practice  of  military  surgeons,  where  fistulous  communications  with 
the  bladder  have  been  caused  by  gun-shot  injuries,  and  maintained 
by  the  lodgment  of  portions  of  the  missiles  and  clothing  or  of  bone 
within  the  viscus.  Unless  there  has  been  an  extensive  breach  of  sur- 
face these  openings  have  usually  healed  on  the  removal  of  the  cause. 
Cases  of  this  kind  point  to  the  necessity  for  a  careful  examination  of 
the  bladder  in  all  instances  where  a  discharge  of  urine  by  the  wound 
indicates  that  a  fistulous  communication  exists.  Abscesses  connected 
with  the  bladder  within  the  pelvis  sometimes  give  rise  to  long  sinu- 
ous tracts  through  which  the  urine  escapes.  In  a  case  I  have  recently 
seen,  the  whole  of  the  urine  was  discharged  through  an  opening  half- 
way down  the  front  of  the  thigh.  I  gave  some  relief  by  establishing 
a  supra-pubic  fistula,  but  as  the  case  was  a  malignant  one,  the  benefit 
the  patient  derived  was  only  temporary. 

Class  4. — Sinuses  between  the  bladder  and  the  vagina.  These  are 
more  generally  known  under  the  name  of  vesico-vaginal  fistulse,  and 
are  for  the  most  part  remedied  by  plastic  operations  effected  from  the 
vagina.  Trendelenburg  ""  records  two  instances  where  he  succeeded 
in  closing  such  fistulse  by  opening  the  bladder  above  the  pubes  by  a 
transverse  incision.  This  enabled  him  to  pare  the  edges  of  the  fis- 
tula, and  to  close  it  with  sutures,  the  knots  of  which  were  made  to 
fall  within  the  vagina.  The  late  Mr.  McGill "  also  recorded  two  sim- 
ilar instances.  It  seems  likely,  however,  that  the  supra-pubic  opera- 
tion will  be  limited  to  exceptional  instances,  where  either  the  fistula 
is  large  or  its  position  is  such  as  to  render  it  desirable  that  the  inte- 
rior of  the  bladder  should  be  seen,  as,  for  instance,  for  the  purpose  of 
avoiding  the  orifice  of  a  ureter.  The  vaginal  operation  is  on  all  other 
grounds  to  be  preferred,  as  it  is  safe  and  not  usually  difiicult.  Men- 
tion may  here  be  made,  in  connection  with  some  very  extensive  forms 
of  vesico-vaginal  fistula  where  a  plastic  operation  is  for  some  reason 
or  other  out  of  the  question,  of  Dr.  N.  Bozeman's  '"  vesical  drainage 
supports.  The  apparatus  consists  of  a  flattened  pear-shaped  metal 
pessary  for  insertion  into  the  vagina,  terminating  in  a  contracted  por- 


276  HAERISON — ^DISEASES  OF  THE   BLADDER. 

tion  to  whicli  a  drainage-tube  is  attaclied.  The  latter  conducts  the 
urine  into  a  bag  secured  to  the  patient's  thigh.  The  upper  surface  of 
the  support  is  concave,  and  perforated  with  holes. 

Class  5. — Sinuses  leading  from  the  bladder  into  the  rectum  through 
the  prostate  or  trigone ; 

(a)  Consequent  on  prostatic  abscess. 

(6)  Following  puncture  of  the  bladder  from  the  rectum,  or  other 
similar  procedure,  or  from  injuries  inflicted  on  the  parts. 

Sinuses  occupying  this  position  can  generally  be  demonstrate^  by 
the  speculum  or  rectal  endoscope.  I  have  found  the  latter  instrument 
of  much  service  in  this  class  of  cases,  as  I  have  on  several  occasions 
been  enabled  to  see  an  opening  which  could  not  otherwise  be  in- 
spected. In  making  an  examination  by  the  endoscope,  the  patient, 
having  previously  had  his  rectum  emptied  both  by  an  aperient  and  an 
enema,  should  be  placed  in  the  lithotomy  position,  when  it  will  be 
found  possible  to  explore  the  bowel  for  at  least  six  inches.  After  the 
aperient  has  acted  it  is  well  to  steady  the  bowels  by  some  astringent 
such  as  chalk  and  opium,  as  Mr.  Howse  suggests.  The  causes  of 
these  sinuses  may  be  divided  into  two  classes. 

(a)  P7'osfatic  Abscesses.  — Matter  formed  in  this  position,  either  aris- 
ing from  tubercular  deposit  in  the  follicles  or  from  follicular  prostatitis, 
will  sometimes  burst  into  the  rectum  and  establish  a  fistulous  com- 
munication. Sinuses  thus  formed  are  difficult  to  heal  by  reason  of 
their  position ;  if,  however,  the  openings  are  small,  and  the  patient  is 
not  suffering  from  urethral  stricture,  but  little  inconvenience  is  occa- 
sioned. In  one  instance,  where  the  rectum  was  much  excoriated  by 
the  constant  dribbling  of  urine,  as  the  opening  could  be  seen  with  a 
speculum,  the  fistula  was  touched  with  a  cautery  wire,  and  the  patient 
was  made  to  lie  on  his  abdomen  for  a  fortnight.  This  expedient 
proved  successful. 

(6)  Fistuke  following  Punctures  and  Wounds. — Cock's  operation  of 
puncturing  the  bladder  above  the  prostate,  and  proceedings  of  a  like 
nature  through  this  part,  have  been  followed  by  fistulous  communica- 
tions. In  these  cases  it  must,  however,  be  remembered  there  is 
usually  the  complication  of  a  urethral  stricture.  The  first  indication 
in  treatment  is  to  remove,  where  practicable,  the  obstruction.  In- 
stances, however,  will  be  found  where  these  fistulse  have  proved  per- 
manent by  reason  of  the  nature  of  the  obstruction,  the  rectum  being 
used  as  a  common  receptacle  for  urine  and  faeces,  and  it  is  remarkable 
how  little  inconvenience  is  suffered  by  some  of  these  persons.  As  a 
rule,  when  the  fistulse  occupy  this  position,  and  are  small,  the  pas- 
sage of  fecal  matter  into  the  bladder  is  seldom  complained  of;  but 
should  the  opening  be  of  such  a  size  as  to  allow  the  contents  of  the 


SINUSES  CONNECTED  WITH  THE  BLADDER.  277 

.  rectum  to  pass  into  tlie  bladder  and  distress  the  patient,  then  the  pro- 
priety of  colotomy  would  have  to  be  considered.  Some  years  ago  I 
met  with  a  patient  who  had  been  operated  upon  in  this  way.  He 
told  me  that  he  passed  all  his  faeces  quite  comfortably  through  a  col- 
otomy, and  reserved  his  rectum  for  his  urine,  as  his  urethra  was  en- 
tirely obliterated  by  an  old  stricture,  I  only  saw  him  on  one  occasion, 
and  had  no  opportunity  of  further  verifying  his  statement,  but  he  ap- 
peared to  be  in  excellent  health. 

Fistulous  communications  of  this  kind  are  sometimes  the  result  of 
injuries  accidentally  received.  The  following  instance  illustrated  a 
remarkable  form  of  injury,  and  a  result  which  was  certainly  better 
than  could  have  been  anticipated : 

Case.— In  1871,  I  saw  a  boy,  aged  14,  who,  in  endeavoring  to  pass 
between  a  railway  wagon  and  locomotive,  became  empaled  on  the 
coupling,  and  was  squeezed  with  much  force.  When  I  examined  him 
there  was  a  lacerated  wound  of  the  rectum,  caused  by  the  entrance  of 
the  hook,  almost  encircling  the  bowel.  The  membranous  urethra  and 
back  of  the  bladder  were  bared,  but  not  torn  across.  Ten  days  after- 
wards it  was  found  that  urine  and  faeces  flowed  from  the  bowel,  which 
was  in  a  sloughing  condition.  Eventually  he  recovered,  but  the  whole 
of  his  urine  was  passed  by  the  rectum. 

I  saw  this  patient  about  fifteen  years  afterward,  and  was  surprised 
to  find,  considering  the  extent  of  his  injuries,  how  comparatively  com- 
fortable he  remained.  The  rectum  answered  fairly  well  the  double 
function  of  bladder  and  bowel.  The  membranous  urethra,  prostate, 
and  a  portion  of  the  posterior  wall  of  the  bladder  were  involved  in 
scar  tissue.  The  case  was  quite  beyond  the  reach  of  any  plastic  oper- 
ation. 

In  one  instance  of  vesico-rectal  fistula  I  had  to  abandon  an  attempt 
to  close  the  false  route  by  a  plastic  operation  conducted  through  a 
supra-pubic  opening,  by  reason  of  the  vesical  aperture  not  correspond- 
ing directly  with  the  intestinal.  Had  I  closed  the  bladder  opening  by 
sutures,  as  I  think  I  could  have  done,  there  still  would  have  remained 
a  considerable  pouch  connected  with  the  intestines,  in  which  fecal 
matter  would  have  lodged.  The  patient  was  a  young  man  who  had 
suffered  from  this  fistula  for  some  years.  The  attempt  thus  made  to 
close  the  sinus  was  followed  by  acute  cystitis,  in  the  course  of  which 
the  entire  mucous  membrane  was  exfoliated  and  removed  like  a  bag 
with  a  hole  in  it  through  the  supra-pubic  opening,  somewhat 
resembling  a  case  previously  described.  The  wound  healed,  but 
the  connection  between  the  bladder  and  bowel  still  exists,  though  it 
has  since  contracted  considerably.  As  a  recurrence  of  calculus  may 
take  place,  there  appears  to  be  no  alternative  but  that  of  establishing 


278  HAEEISON — DISEASES   OF  THE  BLADDER. 

an  artificial  anus  by  opening  the  bowel  at  a  point  above  where  it  com- 
municates with  the  bladder.  Atrophy  of  the  gut  below  the  line  where 
the  artificial  anus  was  made  would  be  likely  to  lead  to  a  closure  of 
the  false  route,  as  happened  in  an  instance  already  referred  to. 

STONE  IN  THE   BLADDER. 

A  stone  in  the  bladder  usually  indicates  its  presence  in  a  variety 
of  ways,  any  one  of  which  may  be  sufiiciently  significant  to  lead  the 
surgeon  to  proceed  to  determine  its  position  by  demonstration  with 
the  hand  and  the  ear.  A  calculus  is,  as  a  rule,  a  source  of  more  or  less 
constant  irritation;  it  frequently  provokes  hemorrhage,  especially 
after  exercise,  and  it  is  generally  associated  with  some  reflex  pain,  of 
which  that  at  the  end  of  the  penis  is  the  most  constant.  Though  in 
the  majority  of  cases  these  symptoms  are  more  or  less  combined  in 
varying  degrees,  we  occasionallj^  meet  with  instances  where  there  is 
perhaps  only  one  prominent  indication.  In  male  children  it  sometimes 
happens  that  constant  preputial  irritation,  or  prolapse  of  the  rectum, 
is  the  only  symptom  suggestive  of  the  presence  of  a  stone  in  the  blad- 
der. A  patient  when  he  first  came  under  my  observation  complained 
only  of  slight  hsematuria  after  taking  a  long  walk,  which  he 
usually  did  once  a  week.  The  constancy  of  this  symptom  in  connec- 
tion with  his  exercise  was  suggestive ;  he  was  sounded,  and  a  lithic 
acid  calculus  detected,  which  was  removed  by  crushing,  when  the 
hemorrhage  disappeared.  It  is  curious  to  notice  that  very  large 
stones  not  unfrequentlj'  give  but  slight  symptoms  of  their  presence. 
In  some  cases,  where  stones  weighing  many  ounces  have  been  removed 
by  the  supra-pubic  operation,  the  patients  appear  to  have  suffered 
but  little  inconvenience  from  them,  probably  because,  by  reason  of 
their  size,  they  became  almost  stationary. 

It  being  important  to  detect  a  stone  in  the  bladder  in  its  earliest 
stage,  we  shonld  not  sanction  the  treatment  of  a  case  of  vesical  irrita- 
bility, otherwise  unexplainable,  without  sounding  the  patient.  It  is 
impossible  for  any  one  to  conclude  from  symptoms  alone  what  a  blad- 
der may  contain  until  a  sound  has  been  introduced,  when  positive 
evidence  is  afforded. 

Sounding  may  be  practised  under  the  following  circumstances, 
when  the  cause  is  not  otherwise  explicable,  or  symptoms  pointing  to 
the  bladder  continue  in  spite  of  treatment :  (1)  In  children  suffering 
from  vesical  irritability,  incontinence  of  urine,  sudden  interruption 
to  micturition,  retention  of  urine,  blood  in  the  urine,  penile  irritation 
inducing  the  pulling  of  the  foreskin,  and  prolapse  of  the  bowel.  (2) 
In  the  vesical  irritability  of  adults  after  attacks  of  renal  colic,  where 


STONE  IN  THE  BLADDER.  279 

there  are  reasons  for  believing  a  calculus  may  be  retained  in  tlie  blad- 
der ;  in  cases  of  liaematuria  of  a  doubtful  nature,  or  of  chronic  muco- 
purulent or  ammoniacal  urine,  or  where  the  urine  contains,  on  stand- 
ing, an  excess  of  cloudy  mucus.  (3)  In  pain  after  micturition, 
referred  to  the  end  of  the  penis.  (4)  In  the  enlarged  prostate  of 
elderly  persons,  with  persisting  symptoms  of  vesical  irritability.  (5) 
Where  calculi,  or  portions  of  them,  have  been  spontaneously  passed, 
and  symptoms  of  irritation  continue.  (6)  In  cases  of  acute  vesical 
spasm  terminating  the  act  of  micturition,  or  where,  though  the  blad- 
der contains  but  little  urine,  there  is  frequently  a  sudden  and  uncon- 
trollable desire  to  micturate.  Though  the  indications  of  stone  may 
be  numerous,  it  will  be  seen  that  they  all  have  reference  to  either  a 
persisting  source  of  irritation  within  the  bladder,  or  a  mechanical  in- 
terference with  the  act  of  micturition.  In  by-gone  days  the  modes  of 
ascertaining  whether  a  patient  had  a  stone  in  his  bladder  were  very 
primitive.  An  old  practitioner  told  me  that  an  eminent  surgeon  of 
the  last  century  often  grounded  his  opinion  upon  this  point  by  the 
manner  in  which  the  person  conducted  himself  on  being  desired  to 
Jump  on  the  ground,  from,  say,  the  height  of  a  chair.  Now,  the  pro- 
cess is  conducted  on  very  different  lines. 

As  a  rule,  I  prefer  that  patients,  when  sounded,  should  have  an 
angesthetic,  not  because  the  process  is  necessarily  a  painful  one,  but 
for  the  purpose  of  making  a  complete  examination.  Formerly,  on  its 
detection,  when  there  was  only  one  method  of  operating  for  stone,  its 
removal  by  lithotomy  naturally  followed.  In  the  present  day,  where 
the  choice  of  procedure  has  been  extended,  more  precise  information 
is  required  before  we  can  determine  whether  the  stone  in  a  given  case 
will  be  better  removed  by  a  crushing  or  a  cutting  operation.  In  ad- 
vising an  anaesthetic  it  is  not  merely  on  the  grounds  that  the  pro- 
cess of  searching  may  be  a  disagreeable  one,  but  also  and  mainly,  in 
cas.es  of  difficulty,  that  a  complete  relaxation  of  the  parts  may  be  se- 
cured. Large,  rigid  prostates  and  contracted  bladders  are  sources 
of  error  which  can  only  be  completely  removed  by  an  anaesthetic.  But 
if  on  sounding  the  patient  it  should  be  proved  that  he  has  not  a  stone 
in  his  bladder,  we  are  often  none  the  less  dependent  on  the  informa- 
tion the  use  of  the  sound  affords  for  our  future  guidance.  In  some 
cases  we  have  to  eliminate  the  possibility  of  disease  in  the  bladder  or 
the  parts  below,  before  the  physician  can  undertake  the  sole  respon- 
sibility of  their  care.  In  others,  though  there  is  no  stone,  there  may 
be  tumor,  tubercle,  or  ulceration,  which  the  skilful  use  of  the  sound 
can  aid  in  determining.  Hence,  as  a  rule,  sounding  must  be  con- 
ducted with  that  deliberation  which  can  only  be  when  an  anaesthetic  is 
employed. .   When  it  is  not  administered  much  of  the  sensitiveness 


280  HAEEISON — DISEASES  OF  THE  BLADDER. 

of  the  deep  urethra  may  be  removed  by  a  preliminary  injection  of 
a  ten-per-cent  solution  of  cocaine  before  passing  the  sound. 

In  the  majority  of  instances,  I  believe  it  is  better  practice  to  sound 
and  remove  the  stone  at  the  same  time.  In  persons  with  fairly  nor- 
mal bladders  the  gentle  movement  of  the  stone  with  the  sound  is  a 
matter  of  little  consequence ;  but  with  stones  more  or  less  fixed  in  one 
position — as  is  so  often  the  case  where  the  prostate  is  large  and  the 
bladder  pouched — the  conditions  and  risks  are  very  different;  urine 
gets  into  the  depression  the  stone  has  so  well  filled,  some  cystitis  is 
set  up,  there  is  an  unnecessary  delaj^  which  is  trying  to  the  nerves 
and  the  sensations  of  the  patient,  the  sleep  is  disturbed ;  and  the  sur- 
geon finds  himseK  almost  obliged  to  operate  (most  probably  by  crush- 
ing) with  a  bladder,  as  well,  perhaps,  as  the  dilated  parts  above,  in- 
fected with  some  of  the  worst  varieties  of  bacteria.  In  a  personal 
experience  of  lithotrity,  now  amounting  to  considerably  over  400 
cases,  I  have  noted  that  not  a  few  of  the  most  rapid  and  complete 
recoveries  followed  when  sounding  and  removal  were  concurrent.  One 
anaesthetic  covers  the  whole  procedure,  and  the  patient  is  spared 
needless  suspense. 

The  risk  connected  with  the  sounding  of  an  adult  who  has  not 
been  in  the  habit  of  using  a  urethral  instrument  is  probably  greater 
than  that  which  attends  the  removal  of  a  moderate-sized  stone  by 
lithotrity  as  now  practised.  In  the  latter  case  all  antiseptic  precau- 
tions are  taken,  and  the  use  of  an  anaesthetic  renders  the  parts  involved 
less  liable  to  any  subsequent  inflammation.  The  tissues  are  thus 
rendered  lax  and  the  process  of  crushing  the  stone  is  both  painless 
and  simple.  Children  and  women,  though  the  risk  of  sounding  is  not 
the  same,  should  invariably  be  spared  through  anaesthesia,  being  either 
alarmed  or  pained  by  having  an  instrument  passed  into  the  bladder. 

In  the  selection  of  instruments  for  sounding  we  all  have  our  pref- 
erences as  regards  curves  and  construction.    I  use  a  solid  steel  sound. 


Fig.  49.— Harrison's  Searcher. 

nickel-plated,  not  exceeding  a  No.  8  English  bougie,  of  the  shape 
here  shown  (Fig.  49) .  Some  sounds  are  so  thick  in  the  shank  that 
they  actually  fit  the  urethra,  and  consequently  the  bulb  of  the  instru- 
ment cannot  be  made  to  pass  as  easily  as  it  should  do  over  all  parts 
of  the  mucous  membrane  of  the  bladder,  including  the  dip  behind  the 
prostate.  As  a  rule,  sounds  are  too  short.  Where  the  prostate  is 
large  they  should  not  be  less  than  fourteen  inches  in  length.     I  have 


STONE  IK  THE  BLADDER.  281 

no  partiality  for  what  are  described  as  hollow  sounds.  Unless  there 
is  some  necessity  for  combining  a  catheter  with  an  explorer  I  would 
sooner  not  incur  the  risk  of  admitting  air  into  an  organ  where  it  may 
do  harm  by  aiding  to  cause  decomposition.  Though  it  is  usually  de- 
sirable to  have  some  fluid  in  the  bladder  when  sounding,  this  can  gen- 
erally be  secured  by  other  means.  A  careful  study  of  the  alterations 
effected  in  the  passage  by  which  the  bladder  is  entered  in  prostatic 
enlargement  leads  me  to  conclude  that  some  variations  in  the  shape 
of  sounds  is  desirable,  though  these  structural  obstacles  usually  dis- 
appear under  an  ansesthetic.  A  long  copper  probe,  sufficiently  flexi- 
ble for  adaptation  to  any  shape  required,  is  an  instrument  I  have  used 
in  instances  such  as  these.  Bigelow  used  to  search  for  stone  with  a 
block-tin  sound,  bent  up  extemporaneously  to  suit  the  case. 

I  generally  pass  a  "whip,"  or  soft  bougie,  before  introducing  the 
metal  sound.  By  this  device  the  closed  urethra  is  opened  and 
greased  and  the  more  rigid  instrument  will  then  slip  in  easier ;  this 
is  equally  important,  whether  or  not  an  anaesthetic  is  used,  as  it  is 
desirable  that  no  damage  should  be  inflicted  on  the  parts  traversed. 
Where  the  prostate  is  large  this  object  is  not  so  easily  attained,  and 
therefore  these  precautions  are  not  superfluous. 

Before  sounding,  an  examination  of  the  urine  is  desirable.  Where 
there  is  any  degree  of  kidney  complication,  rest  in  bed,  warmth,  di- 
luent drinks,  and  doses  of  aconite  or  quinine  have  frequently  pre- 
vented or  moderated  uncomfortable  symptoms  following  sounding. 
To  sound  persons,  as  a  rule,  in  the  consulting  room,  when  seeing  them 
for  the  first  time,  and  perhaps  fatigued  by  a  journey,  is  incurring  a 
risk  which  is  often  unnecessary,  and  which  we  may  have  cause  to 
regret.  In  sounding,  let  it  be  remembered  that  the  instrument  is 
merely  an  imperfect  substitute  for  the  finger,  and  to  obtain  the  infor- 
mation required  it  will  be  necessary  to  conduct  the  operation  with  the 
same  method  as  we  should  adopt  in  the  digital  examination  of  any 
cavity  or  si)ace  in  the  body  which  can  be  so  reached.  To  pass  a 
sound  into  the  bladder,  and  aimlessly  move  it  about  on  the  chance 
that  it  may  touch  a  stone  or  reveal  a  rugged  or  ulcerous  surface,  is 
not  likely  to  be  of  much  service. 

Should  there  be  a  stone,  its  presence  will  probably  be  recognized 
both  by  the  touch  and  the  ear.  A  stethoscope  applied  over  the  pubes 
renders  the  sound  more  audible,  and  may  be  resorted  to  if  there  is 
doubt.  The  size  of  the  stone  can  generally  be  ascertained  by  the 
lithotrite,  while  its  probable  nature  is  indicated  partly  by  the  char- 
acter of  the  note  that  is  obtained ;  the  dull  "  thud"  of  the  phosphates 
is  as  characteristic  as  the  sharper  "click"  of  the  oxalates  or  urates; 
and,  fui-ther,  the  examination  of  the  urine  often  adds  evidence  which 


282  HAEKISON — DISEASES  OP  THE  BLADDER. 

is  conclusive.  Where  there  is  a  suspicion  of  a  stone,  which  cannot 
be  detected  by  sounding  as  described,  an  examination  may  be  made 
on  a  subsequent  occasion,  with  the  patient  in  a  different  position. 
The  sound  may  be  passed  with  the  patient  standing  and  leaning  for- 
ward, with  his  hands  on  the  back  of  a  chair,  and  his  legs  apart,  or 
even  when  lying  on  his  belly. 

The  difficulties  which  arise  in  making  a  diagnosis  of  stone  in  the 
bladder  are  for  the  most  pai"t  traceable  to  the  existence,  as  a  compli- 
cation, of  one  of  the  following  conditions :  First,  the  presence  of  a 
stricture  or  an  enlarged  prostate ;  secondly,  a  diverticulum,  or  recess 
within  the  bladder,  in  which  a  calculus  may  be  lodged ;  and  thirdly, 
the  coating  of  the  stone  with  an  imperfectly  organized,  leather-like 
substance,  which  conceals  it  from  detection  with  the  sound. 

Mr.  Buckston  Browne^'  has  drawn  attention  to  a  source  of  difficulty 
in  detecting  stones  when  lodged  in  what  he  describes  as  a  post-pros- 
tatic  or  trigonal  pouch.  In  such  cases  he  suggests  not  merely  search- 
ing with  the  ,end  of  the  sound  in  the  reversed  position  as  it  lies  in  the 
bladder,  but  with  an  instrument  constructed,  so  far  as  the  beak  is 
concerned,  like  a  flat-bladed  lithotrite.  The  object  of  the  latter  is 
more  readily  to  enter  the  slit-like  opening  of  the  pouch  it  is  desired 
to  explore.  Under  such  circumstances  I  have  found  the  distention  of 
the  rectum  with  a  rubber  bag  of  service  in  bringing  pouched  calculi 
within  reach  of  the  sound  as  well  as  of  the  lithotrite  and  evacuator 
catheter.  '^ 

Examination  of  the  supra-pubic  region  with  the  hand  ought  also 
not  to  be  omitted.  I  was  reminded  of  the  importance  of  this  on  look- 
ing through  the  specimens  in  the  Museum  of  the  New  York  Hos- 
pital. Appended  to  one  (784),  where  there  was  a  sac  larger  than 
a  hen's  egg  opening  into  the  bladder  near  the  fundus,  in  which  were 
several  calculi,  is  the  note :  "  These  calculi  could  not  be  detected  by 
the  sound  during  life,  but  the  pouch  containing  them  could  be  felt 
through  the  abdominal  parietes." 

There  are  probably  no  urinary  cases  presenting  greater  difficulties, 
both  in  diagnosing  and  treating,  than  those  of  rugous  bladders,  where 
phosphatic  concretions  are  deposited  on  elevated  and  circumscribed 
portions  of  the  mucous  membrane.  By  the  sound,  something  closely 
resembling  a  stone  may  be  felt,  but  the  absence  of  a  distinct  "ring," 
as  the  instrument  comes  in  contact  with  the  suspicious  spot,  as  well 
as  its  fixity  in  position — unalterable  by  the  use  of  the  instrument,  by 
changes  in  the  posture  of  the  patient,  and  by  distention  of  the  blad- 
der with  water — render  the  diagnosis  tolerably  easy.  I  have  frequently 
remarked,  in  examining  the  bladders  of  persons  who  have  died  with 
greatly  enlarged  prostates,  or  with  saccules  or  bars  across  them,  how 


STOKE  IN  THE  BLADDER.  283 

impossible  it  would  have  been,  if  tlie  cases  had  been  complicated  with 
stone,  to  detect  it  with  the  ordinary  sound,  provided  the  stone  occu- 
pied a  position  which  could  be  indicated.  These  are  the  instances 
where  symptoms  are  almost  sure  to  arise  simulating  stone,  and  ne- 
cessitating an  exploration  to  determine  this  point. 

In  the  last  place,  the  stone  may  be  so  constituted  as  in  itseH  to 
oppose  a  difficulty  to  its  detection  by  the  means  usually  employed. 

Case. — In  1863,  a  boy  was  admitted  into  the  Liverpool  Royal  In- 
firmary, under  the  late  Mr.  Long,  suffering  from  prolapsus  ani,  pur- 
ulent urine,  and  painful  and  frequent  micturition.  He  was  sounded, 
but  without  any  evidence  of  stone  being  afforded.  Death  occurred 
in  a  few  days.  On  making  a  post-mortem  examination,  the  kidneys 
were  found  disorganized.  The  bladder  was  small  and  contained  a 
calculus,  made  up  of  a  urate  of  ammonia  nucleus  the  size  of  a  damson 
stone,  surrounded  by  a  thick  layer  of  soft  material  consisting  of 
mucus,  fibrin,  and  a  little  gritty,  phosphatic  matter.  The  outer  cov- 
ering could  be  cut  or  torn  easily ;  and  after  it  had  been  in  spirit  it 
presented,  on  section,  a  laminated  appearance,  like  the  fibrinous  lay- 
ers of  an  aneurism.  On  striking  the  mass  with  a  metal  instrument, 
no  ring  was  produced ;  hence  the  impossibility  of  determining  its  ex- 
istence with  the  sound  during  life. 

Mr.  Bickersteth*  records  a  similar  instance. 

Where  the  stone  cannot  be  readily  reached  with  the  sound,  means 
may  be  taken  to  bring  the  two  in  contact.  This  may  be  done  by 
a  plan  which  Dr.  Freyer  suggests :  "  A  most  careful  search  was  made 
by  means  of  sounds  of  various  kinds,  but  no  calculus  could  be 
detected  till  the  aspirator  was  employed,  when  a  distinct  click  was 
felt  during  the  exhaustion  of  the  water  from  the  bladder,  and  due  to 
the  calculus  being  carried  with  force  against  the  eye  of  the  canula  by 
the  outward  stream.  The  sound  of  the  fragments  clicking  against 
the  eye  of  the  canula  during  the  evacuation  of  the  fragments  of  a  cal- 
culus, in  the  operation  of  litholapaxy,  suggested  this  mode  of  diag- 
nosis, and  I  am  now  in  the  habit  of  having  recourse  to  it  when  the 
symptoms  of  stone  are  well  marked,  and  the  sound  fails  to  detect  the 
presence  of  one  in  the  bladder." 

It  should  be  remembered,  as  with  all  surgical  procedures,  how- 
ever slight,  that  the  general  condition  of  a  patient  may  render  even 
sounding  inexpedient  at  the  moment.  I  once  attended  in  consultation 
for  the  i)uri)ose  of  sounding  and  clearing  up  a  case  of  suspected  stone, 
where  we  noticed  at  the  time  that  the  patient  had  a  slight  erythema- 
tous-looking  blush  about  a  trifling  abrasion  caused  by  the  razor  on 

*  Liverpool  Medical  and  Surgical  Reports,  vol.  i. ,  1867.  This  form  of  calculus 
(fibrinous)  appears  to  have  been  first  described  by  Dr.  T.  Hodgkin,  Guy's  Hospital 
Keports,  vol.  ii.,  1837. 


284  HARBISON — DISEASES  OF  THE  BLADDER. 

the  chin.  Soimding  was  consequently  postponed;  fatal  erysipelas 
supervened.  Had  the  sound  or  any  instrument  whatever  been  used, 
death  would  certainly  have  been  attributed  to  it,  as  the  patient  hap- 
pened to  occupy  a  high  social  as  well  as  political  position. 

Liithotrity  or  Litholapaxy. 

I  will  proceed  to  consider  the  treatment  of  stone  in  the  bladder, 
and  as  lithotrity,  litholapaxy,  or  the  crushing  operation,  as  now  prac- 
tised, is  the  one  more  generally  adopted  and  the  safest,  it  will  be 
given  first  place.  If  stones  were  detected  when  small,  there  is  no 
doubt  that  this  method  of  disposing  of  them  would  not  only  supplant 
all  other  mechanical  ones,  but  be  practised  with  as  little  risk  as  at- 
tends any  minor  though  delicate  operation.  It  is  because  a  calculus 
is  permitted  to  attain  considerable  dimensions  that  an  element  of  dan- 
ger is  imported  into  the  question  of  its  removal — an  element  which 
may  be  approximately  stated  as  proportionate  to  the  size  of  the  stone. 
Hence  the  importance  surgeons  attach  to  the  early  detection  of  these 
concretions. 

It  is  not  necessary  at  the  present  day,  in  a  practical  treatise,  to  oc- 
cupy time  by  recording  the  steps  by  which  lithotrity  has  reached  its 
present  position,  or  the  fluctuations  it  has  undergone  within  this  cen- 
tury. It  would,  however,  be  impossible  to  i^roceed  without  noticing 
the  impulse  given  to  Civiale's  proposals  by  the  demonstrations  of 
Otis  and  Bigelow,  in  America,  at  a  time  when  the  prospects  of  litho- 
trity were  beginning  to  wane.  It  is  to  the  former  we  are  indebted  for 
supplying  us  with  a  proper  estimate  of  the  capabilities  of  the  male 
urethra  as  to  size  and  its  power  of  adaptation  to  larger  instruments 
than  were  formerly  used ;  while  to  the  latter  it  was  reserved  to  show 
that  the  bladder  is  more  tolerant  of  prolonged  manipulations  than  was 
supposed,  provided  that,  in  the  case  of  lithotrity,  all  fragments  of 
stone  are  removed  from  it  without  unnecessary  delay. 

In  1878,  shortly  after  an  article  by  the  late  Professor  Bigelow,  of 
Boston,  "On  Lithotrity  by  a  Single  Operation,"®'  appeared,  I  was 
present  at  the  Massachusetts  General  Hospital,  and  saw  him  remove 
a  large  lithic  acid  stone  from  the  bladder  of  a  man  by  a  proceeding 
which  was  different  from  anything  I  had  previously  seen  or  read  of. 
The  chief  points  of  distinction  seemed  to  be  the  recognition,  as  a  prin- 
ciple, of  the  possibility  and  propriety  of  removing  the  entire  stone 
from  the  bladder  at  one  operation,  and  the  employment  of  an  evacu- 
ating apparatus  adequate  to  the  purpose.  In  one  hour  and  nineteen 
minutes,  under  ether,  a  large  lithic  acid  calculus  was  reduced  to  frag- 
ments and  entirely  removed  from  the  bladder,  and  on  the  fourth  day 


LITHOTRITY  OR  LITHOLAPAXY. 


285 


the  patient  was  convalescent.  At  tiiat  date  I  understood  this  opera- 
tion had  been  practised  fourteen  times — including  a  case  each  by  Dr. 
J.  C.  Warren  and  the  late  Dr.  Curtis,  of  Boston — with  but  one  death. 
I  was  much  indebted  to  Dr.  Bigelow,  not  only  for  the  explanation  he 
gave  of  his  method  of  operating,  but  also  for  permitting  me  to  take 
part  in  the  various  manipulations.  In  the  same  year  I  reported  to 
the  British  Medical  Association,  at  Bath,^°  what  I  had  seen,  and  ex- 
hibited, I  believe  for  the  first  time  in  England,  Dr.  Bigelow 's  appa- 
ratus. Shortly  afterward  I  performed  the  new  operation,  and  have 
continued  to  do  so.  In  the  removal  of  some  large  stones  the  time 
taken  up  has  been  considerable.  In  a  successful  case  reported  by 
Professor  Cheever, "  of  Boston,  the  operation  lasted  three  hours  under 
ether,  the  stone  being  composed  of  oxalate  of  lime.  In  a  patient  from 
whom  I  removed  with  safety  a  stone  weighing  upward  of  two  ounces 
the  operation  lasted  over  two  hours.  Reference  is  made  to  such  ex- 
ceptional cases  as  these  merely  to  show  that  there  need  hardly  be  any 
time  limit,  so  long  as 
the  manipulations  are 
carefully  conducted. 
It  will  be  convenient  to 
discuss  the  question 
relating  to  the  selec- 
tion of  an  operation 
in  a  given  case  after 
the  various  details 
have  been  described,  and  I  will  therefore  offer  some  remarks  on  the 
instruments  employed  and  their  use. 

Lithotrites  are  required  of  different  sizes  and  strength,  proportion- 
ate not  only  to  individuals  of  almost  all  ages,  but  to  stones  of  various 
dimensions  and  composition.  These  instruments  are  of  two  kinds, 
smooth-bladed  (Fig.  50)  and  fenestrated  (Fig.  51),  the  former  being 
adapted  to  the  lighter  kinds  of  work,  and  the 
latter  to  the  largest  and  hardest  specimens  of 
stone  which  come  within  the  range  of  lithot- 
rity.  The  modern  instrument  is  constructed 
to  permit  of  the  male  blade 


sliding  within  the  female,  so 
as  to  enable  the  surgeon  to 
seize  the  stone  or  fragment, 
as  the  case  may  be.  This 
is  accomplished  by  means  of  a  button  on  the  handle,  and  without 
moving  the  i>osition  of  his  hands  the  operator  can  fix  the  stone  within 
the  grasp  of  the  instmment,  and  at  the  same  time  bring  into  play  the 


Fig.  50.— Non-Fenestrated  Lithotrites. 


Fia.  51. 


G.TIEMANN-CO. 
-Fenestrated  Lithotrite. 


286 


HAEEISON — DISEASES  OF  THE  BLADDER. 


mecliaiusm  necessary  for  the  screw  or  breaking  movement.  There 
are  other  contrivances  for  accomplishing  ihe  latter  object.  In  many 
of  the  French  instruments  the  change  from  the  slide  to  the  screw  is 

effected  by  a  catch  which  can  be 
elevated  or  depressed  as  required 
by  the  alternate  movement  of 
the  thumbs.  I  think  the  former 
method  is  generallj^  preferable. 
In  bringing  the  screw  action  on  the  stone  into  play,  a  wheel  is  usually 
provided  (Fig.  52),  which  is  grasped  between  the  index  finger  and 
the  thumb. 

The  more  powerful  lithotrites  of  Bigelow  are  fitted  with  a  ball- 
handle  (Fig.  53),  and  rotation  is  thus  effected,  though  I  prefer  the 
wheel  movement.     With  the  former,  I  have  no  doubt,  greater  power 


Fig.  52.— Wheel  Handle  for  Lithotrite. 


Fig.  53.— Bigelow's  Ball-Handled  Lithotrite. 

can  be  obtained,  but  at  the  sacrifice  of  some  delicacy  in  manipulation. 
Knowing  what  the  fenestrated  instrument  with  the  wheel  is  capable 
of  accomplishing,  I  question,  in  the  case  of  a  stone  requiring  greater 
force  than  this,  whether,  with  possibly  some  exceptions,  it  is  pru- 
dent to  select  lithotrity  under  such  circumstances  unless  provided 
with  considerable  practical  experience.  Lithotrites  are  made  of  the 
following  sizes  (English  gauge) : 


FOR  CHILDREN. 

5  in.  stem,  5  in.  bend  of  blades. 

6  do.         6  do. 

7  do.         8  do. 

8  do.        10  do. 


FOR  ADULTS. 

9  in.  stem,  12  in.  bend  of  blades. 
10    do.        14  do. 

12    do.        18  do. 


We  cannot  be  too  careful  in  the  selection  of  these  instruments, 
when  we  consider  the  strain  that  is  put  upon  them  and  the  damage 
that  might  be  occasioned  by  their  bending  or  breaking.  The  best 
material  and  workmanship  should  be  required.  Upon  this  point  Dr. 
Keegan"'  remarks :  "  I  would  warn  the  inexperienced  against  the  fatal 
economy  of  buying  cheap,  and  therefore  badly  made  and  untrust- 
worthy, lithotrites.      There  are  plenty  of  such  instruments  in  the 


LITHOTKITY  OR  LITHOLAPAXY.  287 

market,  and  tliey  may  prove,  even  in  skilled  hands,  most  dangerous 
weapons  of  destruction." 

Care  should  also  be  taken  by  the  operator  in  seeing  that  all  the 
movements  of  the  lithotrite  are  without  hitch  or  friction,  so  that  noth- 
ing may  intervene  between  his  sensation  of  touch  and  the  stone.  The 
smaller  the  calculus  or  fragment  the  greater  is  the  necessity  for  this 
accuracy  in  adjustment.  Further,  it  must  be  ascertained  that  the 
outer  blade  well  protects  the  inner  one,  especially  where  the  stone  is 
seized  and  the  two  parts  of  the  instrument  are  made  to  approximate. 
These  are  points  among  others  which  the  surgeon  should  himseH 
attend  to  and  test  in  selecting  his  lithotrites.  It  is  well  for  the  oper- 
ator to  be  provided  both  with  fenestrated  and  smooth-bladed  instru- 
ments, as  the  latter  are  very  useful,  especially  in  the  case  of  soft 
stones  or  small  fragments.  All  lithotrites  are  liable  to  become  im- 
pacted with  debris;  generally  speaking,  by  reversing  the  screw  action 
and  giving  the  instrument,  whilst  firmly  held,  one  or  two  sharp  taps 
with  a  concussor  of  some  kind,  the  hitch  is  overcome.  It  is  seldom 
that  the  impaction  is  of  such  a  nature  as  to  render  the  closure  of  the 
blades  impossible.  Mr.  Cadge  has  informed  me  that  such  an  occur- 
rence once  happened  in  his  practice.  In  using  a  lithotrite  for  meas- 
uring a  stone  in  a  male  child,  with  the  view  of  ascertaining  whether 
it  could  be  crushed,  on  seizing  the  calculus  and  lightly  closing  the 
blades  upon  it,  he  found  to  his  astonishment  that  the  instrument, 
though  one  of  the  best  of  its  kind,  was  absolutely  locked.  He  could 
neither  close  nor  open  it,  and  no  force  he  could  safely  apply  being  of 
any  avail,  he  performed  a  supra-pubic  cystotomy  on  the  end  of  the 
lithotrite,  and  by  protruding  it  was  able  with  his  finger  to  clear  the 
instrument  from  the  debris  which  had  impacted  it,  the  patient  making 
a  good  recovery. 

The  stone  having  been  broken  into  fragments  by  one  or  more  in- 
troductions of  the  lithotrite,  the  debris  is  removed  by  means  of  a  large- 


FiG.  54.— Harrison's  Evacuator  with  Large  Eye. 


eyed  catheter  and  a  syringe  or  aspirator  filled  with  water.  The  ca- 
theters for  this  purpose  are  of  two  kinds,  straight  and  curved.  The 
largest  I  employ  corresponds  with  No.  26  of  the  French  gauge,  and 
from  this  size  they  gradually  diminish  until  we  come  to  those  appro- 


288 


HAKKISON — DISEASES  OE  THE  BLADDER. 


XJriate  for  children.  The  eyes  of  my  evacuators  (Fig.  54)  are  rather 
larger  than  those  in  general  use.  It  is  very  necessary  that  all  these 
instruments  should  be  provided  with  a  stylet  (Fig.  55)  so  that  they 


Fig.  55. — Evacuating  Catheter,  with  Stylet. 

may  not  become  impacted  with  fragments.  If  an  evacuating  catheter 
is  withdrawn  with  a  sharp  fragment  retained  in  the  eye,  the  urethra 
may  be  wounded  and  much  damage  done.  If  there  is  the  slightest 
resistance  on  attempting  to  withdraw  the  instrument  the  stylet  should 
be  at  once  passed.  Bigelow  preferred  a  straight  evacuator.  They 
are  almost  as  easily  introduced  as  curved  ones,  but  the  latter  are 
generally  used. 

For  withdrawing  the  fragments  from  the  bladder  rubber  aspirators 


Fig.  56.— Bigelow 's  Aspirator. 

are  commonly  employed.  Bigelow' s  original  instru- 
ment and  the  mode  of  using  it  is  shown  in  Fig.  56. 
Morgan's  aspirator  '°  (Fig.  57)  is  the  one  I  generally 
select.  It  has  a  decided  advantage  in  enabling  the 
operator  to  work  it  by  grasping  the  top  of  the  in- 
strument. I  have  had  the  junction  between  the  rub- 
ber bag  and  the  metal  containing  the  trap  connected 
by  means  of  a  bayonet  joint  instead  of  a  screw,  as 
in  the  original  instrument,  which  facilitates  the  process  of  filling  the 
bottle  with  water ;  the  addition  of  the  tap  has  also  proved  a  conven- 
ience. 


LITHOTRITY  OR  LETHOLAPAXY. 


289 


I  have  two  or  three  aspirators  employed  at  an  operation,  one  in 
work  while  the  others  are  being  refilled,  out  of  a  bucket  of  water. 
All  the  evacuators  I  have  tried  are  open  to  the  objection  that  occa- 
sionally fragments  will  be  washed  back  again  in  spite  of  the  trap, 
thus  necessitating  a  second  withdrawal. 

The  possibility  of  washing  back  fragments  by  the  method  of  as- 
piration, as  Just  referred  to,  seems  to  have  led  Guyon  and  others  to 
alter  their  method  of  procedure  in  crushing  and  evacuating  stones. 
This  consists  in  triturating  the  stone  so  finely  by  the  lithotrite  as  to 
enable  the  powdered  particles 
to  run  out  through  a  large- 
eyed  catheter  by  frequently 
filling  the  bladder  with  water' 
by  an  ordinary  syringe.  This 
practice,  I  have  found,  has 
much  to  commend  it.  It  is 
to  be  remembered  that  as  all 
these  aspirators  consist  large- 
ly of  rubber,  care  is  required 
that  they  be  kept  thoroughly 
clean  and  aseptic ;  in  fact,  the 
same  precautions  should  be 
taken  in  regard  to  them  as 
with  catheters. 

Having  thus  referred  to 
some  of  the  instruments  em- 
ployed in  lithotrity,  I  will  now 
proceed  to  speak  of  their  use, 
which  will  best  be  done  by 
taking  an  ideal  case,  where, 
for  instance,  an  adult  male 
otherwise  healthy,  with  a  nor- 
mal bladder,  is  sufi'ering,  we 
will  say,  from  a  lithic  acid  calculus  of  moderate  size.  The  stone 
having  been  discovered  and  lithotrity  decided  upon,  there  are  a  few 
preliminaries  which  may  be  noticed.  In  the  first  place,  due  regard 
should  be  paid  to  those  points  which  we  recognize  as  of  importance 
in  connection  with  all  jjatients  who  are  about  to  undergo  an  opera- 
tion confining  them  for  some  days.  Rest  to  the  parts  involved  and 
regulation  of  the  diet  and  the  bowels  are  attentions  which  will  not  be 
disregarded  as  being  conducive  to  well-doing. 

When  stone  is  comi)licated  with  a  distorted  bladder,  as  in  some 

instances  where  the  ijrostate  is  large,  it  is  not  a  bad  plan  to  turn  the 
Vou  1.-19 


Morgan's  Evacuator. 


290  HAERISON — DISEASES  OF  THE  BLADDER. 

patient  on  his  belly,  after  lie  is  ansestlietized,  and  to  slightly  concuss 
his  body.  Stones  will  often  thus  fall  out  of  a  pouch  into  the  cavity  of 
the  bladder,  and  if  a  small  sponge,  secured  by  a  tape,  is  passed  into 
the  rectum  before  the  patient  is  replaced  on  his  back,  the  seizing  and 
evacuation  of  the  calculus  by  the  lithotrite  and  aspirator  will  be  facil- 
itated.    I  have  several  times  found  this  expedient  of  service. 

At  the  time  of  operation  care  should  be  taken  that  the  patient  is 
well  protected  against  exposure,  and  I  generally  see  that  the  legs  and 
thighs  are  encased  in  loose  flannel  leggings,  which  can  be  readily 
slipped  on,  and  are  also  a  protection  against  wet.  By  this  means 
the  genitals  are  the  only  parts  exposed.  The  patient  should  be  placed 
on  a  suitable  operating  table,  or  its  equivalent,  care  being  taken  that 
its  height  is  proportionate  to  that  of  the  operator.  I  seldom  use 
chloroform,  my  preference  being  either  for  the  combination  of  ni- 
trous oxide  gas  with  ether,  or  what  is  known  as  the  A.  C.  E.  mixture, 
the  latter  consisting  of  one  part  of  alcohol,  two  of  chloroform,  and 
three  of  ether.  I  have  never  had  cause  to  regret  these  selections. 
Mr.  Lawson  Tait^°  has  observed  that  the  administration  of  ether 
sometimes  completely  arrests  the  secretion  of  urine.  He  illustrates 
this  by  a  case  where  for  this  reason  he  failed  to  detect  and  cure  a 
uretero-uterine  urinary  fistula.  When  chloroform  was  substituted 
the  opening  was  discovered  and  closed.  Cocaine  is  not  to  be  relied 
upon  as  being  efficient  so  far  as  lithotrity  is  concerned,  though  it 
suffices  for  such  temporary  purposes  as  the  passing  of  an  instrument 
along  the  urethra.  The  patient  being  anaesthetized  by  a  competent 
administrator,  he  should  first  be  placed  with  the  pelvis  slightly  raised 
on  a  pillow,  a  position  which  may  be  altered  according  to  circum- 
stances. Before  using  any  other  instrument,  I  usually  commence  by 
washing  out  the  bladder  with  boracic  lotion  by  means  of  the  aspirator 
catheter  and  wash-bottle.  This  fulfils  three  objects :  (1)  it  assures  to 
the  operator  a  clean  and  not  a  foul  bladder  in  which  to  work,  (2)  it 
permits  any  small  stones  to  be  withdrawn  without  being  broken,  and 
(3)  it  allows  of  sufficient  fluid  being  left  behind  to  facilitate  the  move- 
ment of  the  lithotrite  in  searching  and  crushing,  and  thus  affords  a 
protection  to  the  mucous  membrane. 

In  commencing  to  crush  and  evacuate,  the  operator  should  en- 
deavor, as  far  as  possible,  to  render  the  proceeding  a  bloodless  one, 
by  causing  damage  neither  in  the  introduction  of  instruments  along 
the  urethra,  nor  in  his  efforts  to  seize  and  crush  the  stone.  It  is  often 
possible  to  conduct  an  operation  of  this  kind,  even  of  some  duration, 
with  but  little  discoloration  of  the  water  in  the  aspirator.  This  is 
difficult  to  accomplish  when  the  prostate  happens  to  be  large  and  ob- 
structive.    Any  extensive  damage  of  this  kind  proves  a  serious  ob- 


LITHOTEITY  OR  LITHOLAPAXY.  291 

stacle  to  the  success  of  lithotrity,  and  when  unavoidable,  is  a  suffi- 
cient reason  for  the  immediate  substitution  of  some  form  of  lithotomy. 
Much  time  may  often  be  saved  in  performing  lithotrity,  not  by  any 
sacrifice  of  safety  to  speed,  but  by  previously  seeing  that  the  nurses 
are  well  versed  in  clearing  the  lithotrites  when  not  in  use,  filling  the 
wash-bottles  (without  air) ,  and  in  recognizing  and  handing  the  exact 
sized  evacuating  tube  the  operator  is  using.  Where  I  have  had  to 
operate  with  excellent  nurses  by  me,  but  unused,  by  reason  of  want 
of  practice,  to  this  kind  of  work,  a  quarter  of  an  hour,  or  even  more, 
has  easily  been  lost,  and  anaesthesia  unnecessarily  prolonged.  This 
is  the  only  kind  of  economy  of  time  that  can  be  justified. 

Stones  of  an  elliptical  or  ovoid  shape  more  commonly  lie  with 
their  long  diameter  in  a  direction  corresponding  with  the  line  of  the 
urethra,  and  are  generally  first  seized  in  this  axis  by  the  lithotrite. 
Hence  calculi  may  appear  larger  than  they  really  are.  My  attention 
was  first  directed  to  this  point  by  my  friend  Dr.  Freyer,  whose  op- 
portunities of  judging  in  reference  to  all  matters  connected  with  stone 
have  been  extensive  in  India.  Naturally  our  object  is  to  seize  the 
stone  in  its  shortest  diameter,  if  we  are  going  to  crush  it,  as  simplify- 
ing the  operation  and  throwing  less  strain  on  the  lithotrite.  Conse- 
quently this  may  necessitate  a  change  in  the  first  position  of  the 
lithotrite  relative  to  the  stone,  for  which,  in  addition  to  other  reasons, 
some  fluid  in  the  bladder  is  required.  In  lithotomy,  on  the  other 
hand,  this  rather  constant  position  of  oblong  stones  relative  to  the 
outlet  from  the  bladder  is  favorable  to  their  more  speedy  withdrawal. 

The  bladder  having  been  cleansed  and  the  lithotrite  introduced,  the 
surgeon  taking  his  place  on  the  patient's  right-hand  side,  the  stone  is 
carefully  sought  for.  This  may  render  it  necessary  to  reverse  the 
position  of  the  instrument  so  as  to  enable  the  operator  to  feel  for  and 
pick  up  anything  which  may  be  lying  behind  the  prostate  in  the  most 
dependent  portion  of  the  bladder.  The  stone  having  been  seized  and 
the  screw  power  adjusted,  the  lithotrite  should  be  slightly  and  gently 
rotated  with  the  left  hand,  so  as  to  see  that  it  is  quite  free  from  the 
coats  or  rugae  of  the  bladder.  I  consider  this  the  most  important 
movement  in  connection  with  the  process  of  lithotrity.  It  may  be 
almost  imperceptible  to  the  casual  observer  by  reason  of  its  delicacy, 
but  it  should  on  no  account  be  omitted.  Its  full  recognition  makes  all 
the  difference  between  an  almost  bloodless  operation  and  otherwise; 
and  further,  it  is  the  means  of  preventing  the  introduction  of  much 
cicatricial  tissue  within  the  bladder  wall.  Probably  there  is  no  opera- 
tion where  more  fineness  in  manipulation  and  i)atience  are  required 
than  in  lithotrity,  as  it  is  entirely  dependent  for  its  success  upon  that 
kind  of  touch  which  is  unaided  by  sight.    A  rough  cicatrix  within  the 


292 


HAEKISON — DISEASES  OF  THE  BLADDEE. 


bladder  may  not  only  act  as  a  foreign  body,  but  prove  the  nucleus 
upon  whicli  a  phosphatic  stone  may  concrete. 

Wlien  operating  in  a  bladder  of  fairly  normal  shape,  with  reason- 
able care,  there  is  little  risk  of  doing  damage  to  the  mucous  mem- 
brane ;  where,  however,  the  prostate  is  enlarged  and  the  surface  of  the 
bladder  rendered  irregidar  by  trabeculse,  elevations  of  its  surface,  and 
depressions  in  which  residual  urine  has  been  lodging,  the  difficulties 
arising  are  not  inconsiderable.  The  operator  should  be  careful  to 
ascertain  that  the  stone  or  fragments  when  seized  by  the  lithotrite 
are  perfectly  free,  and  that  within  the  grasp  of  the  instrument  an 
elevated  portion  of  the  wall  is  not  also  included.     In  Fig.  58  it  will 


Fig.  58.— Wall  of  the  Bladder  Caught  Between  the  Blades  of  the  Lithotrite. 


be  seen  that,  though  the  female  blade  is  in  direct  contact  with  the 
stone,  the  male  blade  is  really  in  a  pouch  behind  the  enlarged  pros- 
tate. This  is  a  very  deceptive  position,  as  the  operator  feels  that  he 
has  the  fragment  within  the  grasp  of  his  instrument.  The  slight  ro- 
tary movement  of  the  lithotrite  by  the  left  hand  of  the  operator,  to 
which  reference  has  been  made,  will  invariably  be  found  sufficient  to 
detect  this  false  position,  before  the  instrument  is  screwed  up  and 
serious  damage  done. 

As  a  rule  the  operator  should  continue  to  use  the  lithotrite  so  long 
as  he  can  pick  up  fragments  readily.  "When  this  ceases,  or  he  feels 
that  his  movements  are  embarrassed  by  the  presence  of  too  much 
debris,  the  aspirator  should  be  substituted,  filled  with  plain  water  or 
boracic  lotion.  In  using  the  lithotrite  and  seizing  very  large  frag- 
ments, as  in  the  earlier  introductions,  when  the  stone  is  hard,  it  is  a 
good  plan  to  screw  it  up  until  the  resistance  offered  by  the  calculus 
is  felt  to  be  considerable.  If  the  operator  will  then  wait  for  a  mo- 
ment or  so,  he  wiU  often  find  the  stone  yield  without  further  force; 


LITHOTRITY  OR  LITHOLAPAXY.  293 

in  this  way  we  may  avoid  putting  the  maximum  amount  of  strain 
on  the  instrument.  This  is  a  matter  of  some  importance  in  grasping 
hard  stones  of,  say,  nearly  two  inches  in  diameter.  Then  again,  in 
picking  up  stones  or  fragments  in  bladders  which  are  more  or  less 
pouched  behind  the  prostate,  it  is  convenient  to  alter  the  position  of 
the  calculus  relative  to  the  bladder  before  pulverizing.  I  sometimes 
say,  "  If  you  take  a  stone  out  of  a  hole  or  depression,  put  it  on  the 
bank  to  break,  and  then  you  may  the  more  easily  deal  with  the  re- 
maining portions  of  it."  I  have  often  demonstrated  how  readily  this 
can  be  done,  and  how  it  simplifies  an  otherwise  difficult  manipulation. 

In  selecting  evacuating  tubes,  the  object  should  be  to  use  the  larg- 
est the  urethra  will  receive,  provided  it  can  be  moved  about  easily. 
In  some  persons  the  meatus  is  so  contracted  that  it  is  necessary  to 
incise  it  before  a  sufficiently  large  tube  will  pass.  Referring  to  the 
size  of  the  evacuating  catheters,  Dr.  Bigelow  remarks :  "  Thirty-one 
is  very  rarely  needed,  and  the  French  sizes,  28  and  29,  are  generally 
the  most  convenient.  For  a  final  washing  or  sounding  without  anses- 
thesia,  when  it  is  desirable  to  give  the  patient  the  least  discomfort, 
even  so  small  a  calibre  as  26  is  sometimes  useful."  "  A  too  tightly 
fitting  catheter  may  damage  the  deeper  portion  of  the  urethra,  which 
is  less  tolerant  of  injury  than  the  bladder. 

I  have  not  found  a  small  quantity  of  air  obstruct  manipulations, 
for  the  reason  that  it  and  the  stone  fragments  occupy  opposite  quar- 
ters in  the  bladder.  If  enough  air  enter  the  bladder  to  interfere  with 
the  withdrawal  of  the  fragments,  or  to  provoke  spasm,  it  is  easily  dis- 
placed by  disconnecting  the  evacuating  tube  from  the  aspirator,  and 
making  pressure  with  the  hand  over  the  pubes. 

When  using  either  the  lithotrite  or  the  aspirator,  the  bladder,  even 
when  the  patient  is  deeply  etherized,  sometimes  exercises  a  violent 
expulsive  efi'ort.  Until  this  is  over,  all  manipulations  should  be  sus- 
pended, otherwise  an  accident  may  possibly  happen.  "Even  deep 
anaesthesia,"  as  Billroth  observes,  "is  not  always  sufficient  to  obviate 
spasmodic  action  of  the  bladder."  ^^  When  manipulating  with  a  con- 
siderable quantity  of  water  in  the  bladder,  if  spasm  comes  on,  all  ten- 
sion should  be  taken  off  by  allowing  an  escape  to  take  place — a  sort 
of  safety-valve  action.  These  are  some  of  the  points  in  connection 
with  breaking  the  stone  with  the  lithotrite  and  removing  it  with  the 
aspirator.  The  best  test  for  the  last  fragment  is  the  suction  power 
of  the  aspirator  bottle,  as  the  piece  is  almost  sure  to  be  felt  impinging 
against  the  eye  of  the  catheter,  claiming  permission  to  escape  in  a  re- 
duced form.  At  the  conclusion  of  an  operation  the  bladder  should  be 
washed  out  with  warm  boracic  lotion  until  it  returns  free  from  dis- 
coloration with  blood.     After  lithotrity  care  must  be  taken  that  the 


294  HAEEISON — DISEASES  OP  THE  BLADDER. 

urine  is  not  retained  beyond  a  reasonable  time,  and,  if  this  should  be 
the  case,  a  catheter  must  be  passed.  Hence  it  is  a  good  plan,  when  the 
stone  has  been  removed  and  before  the  patient  has  become  conscious, 
to  ascertain  what  catheter  passes  most  easily,  which  will  probably  be 
a  soft  one.  Thus  all  further  trouble  in  the  selection  of  an  instrument, 
should  one  be  required,  is  avoided.  Some  surgeons  leave  a  rubber 
catheter  in  the  bladder  for  forty-eight  hours  after  a  lithotrity,  allow- 
ing the  urine  to  drain  away  continuously  into  a  bottle  in  the  patient's 
bed.  If  the  operation  has  been  a  prolonged  one  and  the  urethra  is 
probably  sore,  or  if  the  patient  is  more  or  less  dependent  upon  the 
catheter,  this  is  not  a  bad  plan,  as  it  also  allows  of  the  bladder  being 
washed  out  with  some  antiseptic  lotion  without  disturbing  the  patient. 
In  ordinary  circumstances,  when  the  operation  has  been  simple  and 
the  bladder  and  prostate  are  tolerably  normal,  I  have  not  found  this 
expedient  necessary.  When  the  operation  has  been  a  long  one  and 
the  bladder  is  irritable,  it  is  well  to  introduce  a  suppository  contain- 
ing a  grain  or  so  of  opium  into  the  rectum  before  the  patient  is  re- 
turned to  his  bed. 

Reference  will  presently  be  made  to  some  accidents  which  have 
occurred  in  the  course  of  a  lithotrity.  It  may,  however,  be  well  to 
say  here  that  it  is  a  good  rule  never  to  undertake  lithotrity  without 
having  lithotomy  appliances  at  hand.  Unforeseen  events  connected 
with  the  stone,  the  bladder,  the  urethra,  or  the  instruments,  have 
rendered  the  lithotomy  operation  unexpectedly  necessary,  and  by  re- 
course to  it  a  fatal  termination  has  been  averted.  In  two  of  my  own 
cases,  within  a  recent  period,  I  know  this  result  would  probably  have 
supervened  if  I  had  not  been  able  to  adopt  the  alternative  without  delay. 
In  one  of  those  instances  the  immediate  change  from  lithotrity  to  me- 
dian lithotomy  was  necessary  by  reason  of  a  large  triangular  frag- 
ment becoming  suddenly  forced  by  the  spasm  of  a  powerful  bladder 
into  the  membranous  urethra.  By  the  latter  operation,  with  the  aid 
of  crushing  forceps,  all  the  stone  was  removed  as  well  as  the  impacted 
fragment,  and  the  patient  made  a  speedy  recovery.  In  the  second 
instance,  in  performing  lithotrity  for  an  elderly  man,  the  size  of  the 
stone  felt  and  crushed  was  so  out  of  proportion  to  the  duration  and 
character  of  the  bladder  symptoms,  that  I  was  sure  other  stones  were 
concealed  somewhere  beyond  the  reach  of  the  lithotrite.  I  therefore 
performed  a  median  cystotomy,  which  enabled  me  to  feel  a  distinct 
cavity,  immediately  above  the  prostate,  communicating  with  a  sac, 
out  of  which,  with  a  pair  of  long  forceps,  I  removed  thirty-four  fasci- 
culated lithate  stones,  weighing  altogether  an  ounce  and  a  half. 

Accidents  occurring  in  the  course  of  a  lithotrity  are  fortunately 
rare,  but  some  have  been  recorded  which  may  be  briefly  reviewed. 


LITHOTRITY  OR  LITHOLAPAXY.  295 

They  may  be  classified  under  three  headings  in  connection  with  (1)  the 
instruments  employed;   (2)  the  stone;   (3)  the  soft  parts. 

(1)  A  good  lithotrite  may  break  under  a  strain  beyond  its  power, 
but  I  am  not  acquainted  with  an  instance  of  serious  bending.  The  lat- 
ter mischance  would  probably  be  more  awkward  than  the  former.  The 
breaking  of  a  portion  of  the  crushing  blades  would  most  likely  neces- 
sitate the  immediate  resort  to  a  perineal  or  supra-pubic  cystotomy. 
Dr.  Vander  Veer/'  of  Albany,  U.  S.  A.,  records  an  instance  in  a-male 
adult  operated  on  by  Dr.  N.  L.  Snow,  in  which  the  stone  was  large 
and  hard,  and  the  lithotrite  broke  "  about  half  an  inch  from  the  end, 
leaving  the  portions  of  both  blades  in  the  bladder. "  Lateral  lithotomy 
was  performed,  and  the  fragments  of  stone  and  portions  of  instrument 
were  removed.  The  patient  died  on  the  fifth  day  after  the  operation, 
which  is  stated  to  have  occupied  an  hour  and  a  half.  I  have  no  in- 
formation connected  with  any  important  bending  of  a  lithotrite.  The 
impaction  of  a  lithotrite  with  stone,  so  as  to  render  the  instrument 
immovable,  has  been  previously  illustrated  by  a  case  of  Mr.  Cadge, 
where  the  difiiculty  was  safely  overcome  by  a  supra-pubic  cystotomy. 
To  have  attempted  to  withdraw  the  lithotrite  along  the  urethra  under 
such  circumstances  would  certainly  have  been  fatal.  The  eyes  of  as- 
pirator catheters  may  be  so  firmly  filled  with  stone  fragments  as  to 
impede  their  withdrawal.  When  this  is  the  case  the  instrument 
should  be  cleared  by  means  of  a  stylet.  Hence  the  importance  of  al- 
ways having  the  latter  at  hand. 

(2)  It  has  happened  in  the  course  of  a  lithotrity  that,  by  the  spas- 
modic action  of  a  powerful  bladder,  a  piece  of  the  broken  stone  has 
been  so  firmly  jammed  into  the  deep  urethra  as  to  render  the  further 
stages  of  the  crushing  operation  either  impossible  or  hazardous. 
When  this  is  the  case  it  is  better  to  perform  a  median  cystotomy, 
either  upon  the  fragment  thus  impacted,  or  upon  a  small  staff  which 
may  be  passed  alongside  of  it  into  the  bladder,  rather  than  to  perse- 
vere with  efforts  to  force  the  fragment  back. 

Small  fragments  impacted  in  the  urethra  may  sometimes  be  re- 
moved by  a  pair  of  forceps  with  crocodile  jaws  or  by  gently  pushing 
them  back  into  the  bladder,  where  they  can  be  crushed.  Incidentally 
I  may  mention  a  case  recently  seen  in  which  a  renal  calculus  was  im- 
pacted behind  a  deep  urethral  stricture.  The  stricture  was  dilated 
under  ether,  by  the  successive  introduction  of  Lister's  bulbous  metal 
bougies,  up  to  a  No.  12  English  size.  When  the  patient  recovered 
from  the  effects  of  the  ether,  he  spontaneously  i)assed  the  boracic 
solution  with  which  I  had  filled  his  bladder  with  such  force  as  to 
readily  expel  the  stone.  I  assume  that  it  must  have  been  lodged  there 
for  some  little  time  previously,  and  so  made  a  depression  for  itself 


296  HAERISON — DISEASES   OF  THE  BLADDEE. 

in  the  canal,  otlierwise  it  would  have  been  pushed  back  by  the  intro- 
duction of  the  bougies.  Large  or  irregular  fragments,  however,  can- 
not with  safety  be  treated  in  this  way. 

(3)  In  connection  with  the  preliminary  stages  of  lithotrity  atten- 
tion has  been  drawn  to  the  importance  of  endeavoring  to  avoid  making 
a  simple  operation  a  difficult  one  by  occasioning  any  damage  to  the 
parts,  sometimes  abnormal  and  obstructive,  through  which  the  instru- 
ments-have to  pass  on  their  way  to  the  bladder,  or  in  the  course  of 
their  withdrawal.  Any  serious  damage  of  this  kind  would  probably 
necessitate  a  recourse  to  some  form  of  lithotomy,  as,  if  the  operation 
of  crushing  could  be  brought  to  a  successful  issue  under  such  condi- 
tions of  difficulty  and  embarrassment,  the  prospect  of  eventual  recov- 
ery would  be  considerably  reduced  by  the  complication  necessarily 
attendant  upon  structural  lacerations  of  this  kind.  Such  complica- 
tions would  be  likely  to  be  more  serious  in  their  results  than  those 
usually  attending  the  direct  wound — for  instance,  of  a  median  cystot- 
omy provided  with  suitable  drainage.  Instances  have  been  recorded 
when — from  an  unnatural  thinness  of  its  walls,  from  spasm,  or  from 
an  undue  amount  of  force,  as,  for  instance,  in  the  case  of  a  child — the 
bladder  has  been  ruptured.  If  the  lesion  is  known  to  have  occurred 
on  the  peritoneal  aspect  of  the  viscus,  a  laparotomy  with  the  object 
of  closing  the  rent  would  be  indicated ;  whereas  if  it  were,  as  in  a 
specimen  I  once  saw  at  a  medical  society,  in  the  floor,  a  lateral  lith- 
otomy, by  providing  a  means  for  immediately  producing  urinary  in- 
continence, would  give  a  chance  of  recovery.  A  lesion  occurring 
under  such  circumstances  is,  however,  seldom  recognized  until  after 
death. 

In  reference  to  the  immediate  after-treatment  of  lithotrity  there 
is  not  much  to  be  said.  A  successful  operation  now  leaves  little  more 
to  be  done  than  what  is  included  under  the  terms  warmth,  rest,  care- 
ful nursing,  suitable  diet,  and  a  complete  discharge  of  urine  at  regu- 
lar intervals.  If  the  operation  is  followed  by  some  degree  of  local  in- 
flammation and  there  is  reason  to  suspect  the  presence  of  fragments, 
their  immediate  withdrawal  is  the  proper  course  to  take.  The  possi- 
bility of  such  a  contingency  as  incomplete  removal  must  be  recognized 
in  connection  with  lithotrity,  since  some  part  of  the  bladder  may  be 
rendered  difficult  of  access.  It  should  not  be  forgotten  that  a  stone 
is  a  foreign  body  which,  to  a  certain  extent,  the  bladder  has  learnt  to 
tolerate ;  but  a  broken  calculus,  combined  with  the  circumstances  at- 
tending its  fracture,  is  capable  of  exciting  the  most  urgent  signs  of  its 
altered  shape. 

After  lithotrity  care  should  be  taken  to  see  that  the  urine  has 
returned  to  a  normal  condition,  both  in  appearance  and  composition, 


LITHOTRITY  OR  LITHOLAPAXY.  297 

before  tlie  case  is  considered  as  completed.  This  is  more  particu- 
larly necessary  in  those  instances  where,  in  addition  to  the  stone,  the 
case  is  further  complicated  by  a  large  prostate,  a  pouched  or  saccu- 
lated bladder,  or  such  a  state  of  atony  as  to  render  the  patient  more  or 
less  dependent  on  the  catheter.  The  urine  should  be  clear  and  free 
from  evidence  of  shreds  or  masses  of  lymph,  like  feathers,  since  these 
are  capable  of  providing  not  only  material  for  decomposition,  but 
for  the  aggregation  upon  them  of  phosphatic  particles.  A  clean  blad- 
der and  clear  urine  present  conditions  under  which  it  is  almost  im- 
possible for  a  recurrence  of  triple-phosphate  stone  to  take  place. 
Until  these  conditions  are  secured,  attention  to  the  toilet  of  the  blad- 
der may  be  required  as  referred  to. 

When  after  lithotrity  the  urine  remains  loaded  with  mucus,  bene- 
fit is  often  derived  by  injecting  into  the  bladder,  with  a  rubber  catheter 
and  glass  syringe,  a  watery  solution  of  nitrate  of  silver  in  the  pro- 
portion of  haK  a  grain  to  the  ounce.  Two  or  three  ounces  of  this 
may  be  used  and  a  portion  left  behind  in  the  bladder,  for  voluntary 
expulsion.  For  a  similar  purpose  acetate  of  lead,  half  a  grain  to  the 
ounce  of  water,  or  dilute  nitric  acid,  one  or  two  drops  to  the  ounce, 
may  be  employed  until  the  excess  of  mucus  is  removed.  If  after  a 
lithotrity  symptoms  of  vesical  irritation  continue,  such  as  frequent  or 
painful  urination,  disordered  urine,  and  the  like,  the  surgeon,  in  his 
patient's  interest  as  well  as  his  own,  will  do  well  not  to  permit  treat- 
ment to  be  concluded  without  a  thorough  examination  of  the  bladder 
under  an  anaesthetic.  Fragments  may  escape  notice  at  the  time  of 
the  operation,  or  concealed  stones  may  be  extruded  into  the  general 
cavity  of  the  bladder  from  pouches  and  depressions  where  the  instru- 
ment could  not  reach,  which  if  allowed  to  remain  would  rapidly  repro- 
duce the  original  state  of  things.  This  is  specially  of  importance  to 
remember  where  the  prostate  is  more  or  less  enlarged.  Such  a  safe- 
guard as  this  can  in  no  way  reflect  on  the  skill  of  the  surgeon,  while 
the  patient  is  xjrotected  from  the  possibility  of  an  oversight.  It  is  a 
provision  for  making  doubly  secure  which  no  prudent  operator  or  re- 
flective patient  can  take  exception  to.  Lithotrity  in  elderly  men 
with  enlarged  prostates  and  partially  atonic  bladders  is  occasionally 
followed  by  a  complete  and  permanent  dependence  on  the  use  of  the 
catheter.  Some  bladders  positively  seem  better  able  to  discharge  the 
urine  they  contain  when  a  stone  is  present,  reminding  one  somewhat 
of  the  old  fable  of  the  stork  and  the  narrow  necked-pitcher. 

Since  the  introduction  of  Bigelow's  method  of  operating,  the  mor- 
tality as  well  as  the  x^eriod  of  convalescence  connected  with  the  oper- 
ation have  undergone  considerable  reduction.     It  is  not  unusual  to 
^  meet  with  instances  in  which  recovery  may  be  said  to  be  completed 


298  HAERISON — DISEASES  OF  THE  BLADDER. 

wittin  a  week,  even  wlien  stones  of  a  considerable  size  and  hardness 
have  been  removed.  VVitliont  going  into  statistics,  there  is  no  doubt 
that  the  mortality  connected  with  lithotrity  is  not  only  very  small, 
but  has  been  much  reduced  since  the  adoption  of  the  Bigelow  method. 
If  stones  were  dealt  with  in  this  way  when  as  y^t  small,  it  would  be 
practically  7iil.  Phlebitis  after  lithotrity  is  now  rarely  seen,  owing 
to  antiseptic  precautions  and  improved  instruments. 

I  think  it  will  be  generally  conceded  that,  for  all  calculi  of  a  mod- 
erate size  occurring  in  otherwise  healthy  male  adults,  lithotrity  is  the 
treatment  which  will  give  the  best  results  with  the  least  risk  to  life, 
Wliere  stones  are  unusually  large,  or  complicated  with  disease  in  the 
urethra,  prostate,  bladder,  or  kidneys,  it.  cannot  be  said  that  there  is 
a  consensus  of  oi:)inion  as  to  the  best  method  of  procedure.  When 
calculus  is  associated,  as  is  often  the  case  in  elderly  men,  with  en- 
largement of  the  prostate,  unless  this  is  considerable  or  umisual,  lith- 
otrity is  not  contra-indicated,  though  if  there  is  much  difficulty  in 
finding  or  handling  the  stone  with  the  lithotrite,  it  may  be  expedient 
to  substitute  lithotomy.  Under  the  same  condition,  an  inability  to 
discharge  the  urine  from  the  bladder  spontaneously  may  be  a  reason 
why  it  is  safer  to  discard  lithotrity.  In  the  after-treatment  of  lithot- 
rity, when  the  bladder  is  atonic  or  much  pouched  above  the  prostate, 
I  make  the  patient  lie  on  his  belly  for  some  time  every  day  after  the 
bladder  has  been  emptied.  This  has  often  proved  of  service  in  pro- 
moting both  the  drainage  and  contraction  of  the  pouches,  and  is 
sometimes  combined  with  the  local  use  of  nitrate  of  silver  as  pre- 
viously described. 

When  stone  and  tumor  of  the  bladder  coexist,  supra-pubic  lithot- 
omy would,  as  a  rule,  be  indicated  in  preference  to  lithotrity,  as  the 
former  permits  of  the  tumor  being  explored  and  removed,  if  this  be 
found  practicable  on  inspection.  In  a  case  of  this  kind,  reported 
by  Dr.  Alexander,"'  where  he  performed  supra-pubic  lithotomy,  and 
removed  a  stone  from  a  cancerous  bladder,  we  have  an  illustration 
of  what,  perhaps,  is  best  to  be  done  under  these  circumstances. 

Suppression  of  urine  after  lithotrity  is  a  serious  complication,  and 
for  the  most  part  happens  in  patients  with  unsound  kidneys  when  the 
operation  has  been  of  a  prolonged  character.  For  the  management 
of  this  symptom  reference  may  be  made  to  the  subject  of  urethral  or 
urinary  fever.  As  in  other  disorders,  where  operative  treatment  has 
to  be  considered,  advanced  structural  kidney  disease  is  unfavorable 
both  for  lithotomy  and  for  lithotrity.  It  is,  however,  a  question  of 
degree,  which  often  requires  fine  balancing,  and  where  some  previous 
knowledge  of  the  patient  and  his  constitution  is  of  assistance. 
Whether  under  such  circumstances  to  remove  the  stone  by  lithotrity 


LITHOTRITY  OR  LITHOLAPAXT.  299 

or  by  lithotomy,  or  not  to  attempt  either,  are  questions  involving 
grave  responsibility,  which  cannot  be  answered  by  rules  having  gen- 
eral rather  than  individual  application.  More  than  one  case  has  come 
under  notice  in  which  I  have  advised,  with  regard  primarily  to  the 
serious  state  of  the  kidneys  or  other  vital  organs,  that  the  removal  of 
stone  should  not  be  attempted,  and  have  had  the  satisfaction  of  believ- 
ing that  the  course  adopted  has  been  the  means  of  permitting  a  per- 
son to  live  out  his  days  with  not  more  discomfort  than  surgery  could 
entirely  alleviate. 

Stricture  of  the  urethra  sometimes  complicates  stone  in  the  blad- 
der. In  one  instance  which  I  saw,  with  Dr.  E.  Adam  of  Liverpool, 
of  a  middle-aged  man,  where  lithotrity  was  performed,  the  result  was 
not  satisfactory. 

Case. — Seven  days  after  the  operation,  and  when  the  patient  had 
left  the  Infirmary,  rupture  of  the  urethra,  behind  the  stricture,  and 
extravasation  of  urine  suddenly  took  place  and  caused  death,  in  spite 
of  incisions  wherever  the  vitality  of  the  tissues  was  threatened. 
Though  the  operation  was  simple,  and  the  water  in  the  aspirator 
hardly  tinged  with  blood,  it  is  possible  that  the  manipulations  may 
have  further  weakened  a  urethra  which  had  been  long  diseased,  and 
so  contributed  to  the  fatal  result.  Before  performing  lithotrity  I  had 
dilated  the  urethra,  so  that  the  lithotrite  passed  readily. 

In  a  similar  case,  in  which  the  stricture  is  at  all  tight  or  chronic, 
I  should  prefer  perineal  lithotrity,  as  it  is  not  always  possible  to 
avoid  the  contingency  to  which  all  persons  suffering  from  stricture 
are  liable — namely,  peri-urethral  abscess  and  extravasation  of  urine, 
which  in  this  instance  caused  the  death  of  the  patient,  though  it 
might  have  been  entirely  unconnected  with  the  removal  of  the  stone. 

The  presence  of  saccules  or  recesses  in  the  bladder  offers  an 
obstacle  in  the  way  of  lithotrity,  and  where  they  are  known  to  exist 
lithotomy,  as  a  rule,  is  indicated.  An  extensively  sacculated  bladder 
is  unfavorable  for  lithotrity,  as  though  by  means  of  the  latter  opera- 
tion the  stone  may  be  completely  removed,  the  physical  condition  of 
the  bladder  is  rarely  thereby  improved.  Saccules  may  conceal  other 
stones  as  well  as  lodge  fragments.  I  saw  an  instructive  case  in  the 
practice  of  my  colleague,  Mr.  Swinford  Edwards,  at  St.  Peter's  Hos- 
pital. He  had  crushed  a  stone  of  some  size  under  difficulties  arising 
from  a  contracted  bladder  and  a  large  prostate,  where  considerable 
time  was  occupied.  Two  months  afterward,  all  the  symptoms  of 
stone  having  returned,  Mr.  Edwards  performed  median  cystotomy  and 
took  out  of  sacs  communicating  by  small  mouths  with  the  general 
cavity  of  the  bladder  three  large  urate  stones  coated  with  phosphates. 
If  stones  are  difficult  to  find  under  such  circumstances  with  the  fin- 


300  HARRISON — DISEASES  OF  THE  BLADDER. 

ger  and  the  forceps,  when  the  bladder  is  laid  open,  how  can  we  be 
surprised  if  they  occasionally  escape  the  reach  of  the  sound  or  the 
grip  of  the  lithotrite?  I  have  previously  alluded  to  a  somewhat  simi- 
lar case  where  I  abandoned  lithotrity  and  by  a  median  lithotomy  took 
out  of  a  sac  above  the  prostate  thirty-four  stones  weighing  altogether 
about  an  ounce  and  a  haK. 

On  the  completion  of  a  crushing  operation,  the  amount  of  frag- 
ments removed  should  be  approximately  jDroportioned  to  the  size  of 
the  stone,  as  determined  by  the  lithotrite.  This  may  be  estimated 
by  putting  the  debris  in  a  handkerchief  or  piece  of  thin  linen,  and 
then  screwing  it  up  within  the  folds  so  as  to  form  a  globular  mass. 
Dr.  Alexander  "  reports  a  case  of  stone  with  sacculation  of  the  female 
bladder  where  vaginal  lithotomy  was  performed,  and  subsequently 
ligature  and  amputation  of  the  sac,  with  a  good  effect. 

A  few  remarks  may  be  made  in  reference  to  the  employment  of 
lithotrity  in  male  children.  Having  regard  to  the  good  results  ob- 
tained from  lithotomy,  it  seems  almost  unnecessary  to  suggest  any 
other  operation.  Such  was  my  opinion  until  some  years  ago,  when 
I  happened  [to  be  examining  a  number  of  calculi  removed  from  chil- 
dren which  were  so  small  as  to  be  capable  of  being  pulverized  by  one 
or  two  grips  of  the  lithotrite.  Working  in  this  direction,  and  making 
some  experiments  with  calculi  of  various  size  and  composition,  I  came 
to  the  conclusion  that  small  stones  might,  in  male  children,  be  readily 
disposed  of  with  the  lithotrite  without  damage  to  either  the  urethra 
or  bladder. 

Surgeon-Major  Keegan  "^  has  added  important  testimony  in  favor 
of  litholapaxy  in  male  children,  having  practised  this  operation 
largely  in  India  with  results  which  have  been  most  satisfactory.  The 
experience  of  lithotomy  in  children  has  been  so  generally  favorable 
that  I  should  not  feel  disposed  to  materially  extend  the  limit  I  have 
illustrated.  Many  practitioners,  who  are  expert  lithotomists,  would 
fail  to  find  the  same  success  in  their  application  of  the  crushing  oper- 
ation to  male  children.  Some  instances  have  been  recorded  "  where 
the  bladder  was  ruptured  in  performing  lithotrity,  and  it  is  probable 
that  we  should  have  further  examples  of  this  if  the  practice  were  much 
extended. 

Measures  Employed  for  the  Removal  of  Stone  from  the 
Bladder  Other  than  by  Crushing  Alone. 

In  exceptional  cases,  operations  other  than  lithotrity  may  be  ne- 
cessary, and  I  shall  consider  those  varieties  of  lithotomy  which  at  the 
present  time  are  more  usually  selected.     They  include  those  where 


LITHOTOMY.  301 

the  bladder  is  approached  (1)  from  the  perineum,  and  (2)  from  above 
the  pubes. 

Lateral  lithotomy  is  an  operation  which  has  been  extensively- 
practised  in  the  male  at  all  periods  of  life.  Recently  its  application 
has  been  restricted,  partly  by  reason  of  the  more  general  adoption, 
in  some  form  or  other,  of  lithotrity,  and  partly  in  consequence  of  cer- 
tain advantages  which  the  supra-pubic  method  undoubtedly  possesses. 
In  the  pre-ansesthetic  days,  when  the  sufferings  of  the  patients  under- 
going such  proceedings  required  first  consideration,  and  when  speed  in 
the  performance  of  an  operation  was  an  important  element,  there  was 
much  to  be  said  in  favor  of  a  method  by  which,  under  advantageous 
circumstances,  the  operation  has  been  ended  within  a  minute  by  the 
watch.  This  is  now  all  changed,  and  other  considerations  have  our 
first  claim.  Lateral  lithotomy  has  much  to  recommend  it,  on  the 
ground  that  it  provides  a  ready  and  sufficient  access  to  the  bladder 
for  the  removal  of  stones  of  a  considerable  size,  and  at  the  ^ame  time 
enables  the  surgeon  to  satisfy  himself,  almost  beyond  question,  that 
the  whole  of  the  stone  therein  contained  has  been  removed.  Li  addi- 
tion, it  secures  a  means  for  the  continuous  and  incontinent  drainage 
of  the  bladder  in  a  convenient  and  dependent  position  for  as  long  as 
it  may  be  necessary.  Mainly  for  these  reasons,  coupled  with  the 
small  mortality  that  attends  it,  at  all  events  in  early  life,  it  has  ob- 
tained in  the  past,  as  well  as  at  the  present,  the  confidence  of  many 
surgeons  of  large  experience  in  connection  with  this  class  of  disor- 
ders. These  are  grounds  for  its  selection  which,  when  combined  with 
personal  dexterity  and  accuracy  in  its  performance,  are  beyond 
gainsay. 

The  patient  being  placed  under  an  anaesthetic,  and  retained  in  the 
lithotomy  position  by  the  crutch  or  anklets,  a  full-sized  staff  with  a 
lateral  groove  is  passed  into  the  bladder,  and  held  there  by  an  assis- 
tant. In  young  males,  in  whom  the  bladder  is  an  abdominal  rather 
than  a  pelvic  organ,  it  must  be  held  more  obliquely  downward  than 
in  the  adult ;  otherwise,  as  the  curve  is  a  short  one,  the  extremity 
of  the  instrument  may  hardly  be  within  the  viscus.  The  bladder 
should  contain,  in  the  adult,  at  least  three  or  four  ounces  of  fluid,  in 
order  that  the  walls  of  the  viscus  may  be  kept  somewhat  apart.  Pre- 
vious to  the  operation  an  empty  and  contracted  rectum  should  be  se- 
cured. Lithotomy  is  one  of  the  few  operations  in  which  from  first  to 
last  there  need  be  no  change  in  the  way  the  knife  is  held,  as  shown 
in  Fig.  59.  No  other  position  permits  that  freedom  of  movement 
which  is  necessary  for  its  dexterous  performance.  Commencing  about 
an  inch  in  front  of  the  anus,  the  point  of  the  knife  should  be  steadily 
directed  toward  the  staff,  with  the  view  of  touching  it  in  the  mem- 


302 


HARBISON — DISEASES  OF  THE  BLADDER. 


branous  uretlira,  below  the  line  of  tbe  bulb,  the  incision  being  en- 
larged downward  and  outward  as  the  knife  is  withdrawn,  to  the  extent 


Fig.  59.— Mode  of  Holding  the  Knife  for  Lithotomy. 

of  about  two  inches,  or  even  more,  so  far  as  the  superficial  structures 
are  concerned,  should  the  size  of  the  stone  require  it.  It  is  as- 
sumed that  the  surgeon  has  been  able  to  form  a  tolerably  accurate 
notion  of  the  size  of  the  stone  to  be  removed.  If  the  incision  is  fully 
made,  both  in  depth  and  direction,  the  staff  will  at  once  be  felt  by  the 
finger  of  the  other  hand,  or  be  so  nearly 
bared  as  only  to  require  a  touch  or  so  with 
the  point  of  the  knife.  The  bladder  is  then 
opened  by  cautiously  pushing  on  the  knife  in 
the  groove  of  the  staff,  the  edge  being  directed 
obliquely  outward,  so  as  to  incise  the  prostate 
in  a  direction  corresponding  with  its  greater 
radius. 

Curved  and  straight  pairs  of  lithotomy 
forceps  should  be  at  hand,  and,  in  withdraw- 
ing the  stone,  only  gentle  traction  forward 
and  slightly  downward  is  to  be  exercised. 
Angular  stones,  or  those  with  spike-like  pro- 
cesses, are  sometimes  more  or  less  embedded 
in  the  walls  of  the  bladder.  When  this  is  the 
case,  the  position  of  the  calculus  must  be 
altered  before  it  can  be  withdrawn  by  the  for- 
ceps, otherwise  the  floor  or  neck  of  the  blad- 
der may  be  torn.  I  have  known  stones  ren- 
dered stationary  in  this  manner  spoken  of  as 
being  adherent  to  the  walls  of  the  bladder, 
such  a  connection  being,  of  course,  only  a 
mechanical  one.  It  is  well  to  have  one  or  two 
different-shaped  forceps  in  readiness  so  as  to  secure  a  fairly  accurate 
adaptation  to  the  stone.  Fig.  60  shows  how  an  unnecessary  amount  of 
room  may  be  taken  up  where  the  forceps  and  stone  are  not  well  fitted 


Fig.  60.— Lack  of  Adaptation 
of  Forceps  to  Stone. 


LITHOTOMY.  303 

to  each  otlier.  A  scoop  and  a  Higginson's  syringe  for  washing  out  the 
bladder  through  the  wound  are  sometimes  required  when  the  stone 
breaks  on  being  seized  with  the  forceps.  Sir  George  Humphry  seems 
to  have  a  preference  for  the  scoop."  When  the  stone  is  large,  too  large 
to  come  away  without  the  exercise  of  such  force  in  extraction  as  might 
tear — not  stretch — the  neck  of  the  bladder,  a  corresponding  incision 
on  the  opposite  side  of  the  prostate  may  be  made  with  a  straight 
probe-pointed  knife  on  the  operator's  left  index  finger  passed  fairly 
within  the  bladder,  should  an  extension  of  the  existing  incision  be 
insufl&cient.  On  some  occasions  I  have  thus  made  a  bilateral  incision 
with  success.  In  one  instance  where  it  was  employed,  it  permitted 
me  to  remove,  without  hemorrhage,  a  prostatic  tumor  (an  adenoma) 
in  addition  to  an  oxalate  stone  weighing  nearly  three  ounces. 

To  any  one  practically  unacquainted  with  lateral  lithotomy  it  may 
appear  that  attention  to  the  many  details  it  includes  must  necessitate 
some  time  being  taken  up  in  its  performance.  Such  however,  is  not 
the  case ;  and  though  care  is  to  be  commended  rather  than  speed, 
there  is  nothing,  in  cases  free  from  complication,  to  prevent  the  oper- 
ation being  safely  accomplished  in  a  few  seconds.  Eapidity  in  ma- 
nipulation must,  however,  come  naturally  rather  than  be  aimed  at. 
The  object  of  the  operator  is  to  extract  the  stone  from  the  bladder 
without  exposing  the  patient  to  unnecessary  risk,  and  so  long  as  the 
surgeon  accomplishes  this,  he  may  regard  the  time  occupied,  what- 
ever it  may  be,  as  well  spent. 

After  a  stone  has  been  extracted,  the  bladder  should  be  carefully 
searched  to  ascertain  that  it  is  clear.  The  index  finger  is  the  most 
trustworthy  explorer,  aided  by  downward  pressure  with  the  other  hand 
above  the  pubes.  If  these  means  be  found  insufiicient,  an  ordinary 
sound  may  be  introduced  through  the  wound.  I  usually  introduce 
a  drainage-tube  through  the  wound  into  the  bladder  to  prevent  any 
clots  obstructing  the  free  discharge  of  urine.  If  there  is  considerable 
oozing  of  blood  from  vessels  that  cannot  be  tied,  I  make  the  tube  fit 
accurately  by  the  introduction  of  one  or  two  sutures  either  above  or 
below  it.  When  an  artery  has  been  divided,  and  is  evidently  spout- 
ing, it  must  be  tied ;  this  can  generally  be  done  without  much  diffi- 
culty with  the  aid  of  retractors ;  to  plug  a  severed  vessel,  if  it  is  possi- 
ble to  avoid  it,  is  to  court  the  recurrence  of  bleeding.  More  usually  I 
have  noticed  in  section  of  the  prostate  and  the  adjacent  parts  that  the 
bleeding  is  of  an  oozing  nature,  as  if  from  spongy  textures,  but  in  this 
way  many  ounces  of  blood  may  be  lost.  For  restraining  hemorrhage 
Mr.  Buckston  Browne's  dilatable  tampon  may  be  found  serviceable. 

Hemorrhage  from  the  deep  portion  of  the  urethra,  as  occasionally 
happens  after  lithotomy,  may  also  be  arrested  by  distending  the  rec- 


304  HAEEISON — DISEASES  OE  THE  BLADDER. 

turn  either  by  a  plug  or  an  air  bag  as  is  sometimes  used  with  supra- 
pubic cystotomy.  Where  this  expedient  is  adopted  the  precaution 
should  be  taken  of  passing  a  gum-elastic  drainage-tube  through  the 
wound  into  the  bladder  so  as  to  provide  an  escape  for  the  urine. 
This  device  tends  to  close  rather  than  distend  the  wound  that  has 
been  made. 

As  to  the  after-treatment  of  lateral  lithotomy  there  is  little  to  be 
said  beyond  what  applies  to  all  operations  in  surgery,  in  regard  to 
cleanliness,  drainage,  ventilation,  and  j)roper  feeding.  The  old  sur- 
geons, on  visiting  a  patient  after  lithotomy,  were  in  the  habit  of  asking, 
Does  he  wet  well?  To-day  we  should  say,  How  does  he  drain?  The 
drainage  of  the  wound  is  favored  by  slightly  elevating  the  head  of  the 
bed,  and  the  patient  is  to  be  kept  dry  by  a  good  supply  of  ordinary 
or  wood-wool  draw-sheets.  The  food  should  be  of  such  a  character 
as  not  to  require  an  action  of  the  bowels  for  some  days,  the  first 
movement,  if  not  spontaneous,  being  promoted  by  a  warm-water 
enema. 

The  chief  objections  urged  against  lateral  lithotomy,  apart  from 
the  fact  that  the  operation  is  one  entailing  considerable  skill  in  its 
performance,  are  based  on  some  isolated  cases  when  a  fistulous  tract, 
incontinence  of  urine,  or  sterility  have  followed  it.  "When  this  has 
been  the  case  such  consequences  are  usually  traceable,  not  to  any 
fault  in  the  original  design  of  the  operation,  but  to  unanticipated  cir- 
cumstances which  have  arisen  in  individual  cases  entailing  a  greater 
section  or  distention  of  the  parts,  either  with  the  knife  or  in  the  with- 
drawal of  the  stone.  Where  care  is  taken  to  provide  against  such 
contingencies  by  keeping  the  incision  within  the  defined  bounds,  and 
the  stone  within  the  dimensions  thus  made  for  its  removal,  as  will  be 
referred  to  later  in  connection  with  perineal  lithotomy,  such  conse- 
quences need  not  be  apprehended.  This  operation  was  frequently  re- 
ferred to  by  the  late  Sir  William  Fergusson  as  "  the  master-handiwork 
in  surgery." 

The  median  operation  for  stone  may  be  regarded  as  the  simplest 
proceeding  where  the  use  of  the  knife  is  required.  It  is  conducted  in 
accordance  with  the  direction  given  previously  for  drainage  punctures, 
the  incision  being  made  somewhat  larger  so  as  to  permit  of  the  intro- 
duction of  the  lithotomy  forceps  and  the  withdrawal  of  the  stone. 
After  this  has  been  done  a  drainage-tube  should  be  passed  into  the 
bladder,  otherwise  retention  of  urine  or  a  rigor  is  not  unlikely  to  fol- 
low. As  thus  practised  it  is  limited  to  small  stones  only,  which 
might,  as  a  rule,  be  easily  disposed  of  with  the  lithotrite.  It  is,  how- 
ever, capable  of  being  adapted  to  much  larger  calculi  in  two  different 
ways :    (1)  by  the  extension  of  the  incision  so  as  to  give  more  room 


LITHOTOMY.  305 

for  whatever  has  to  be  withdrawn  from  the  bladder ;  and  (2)  by  com- 
bining it  with  means  for  crushing  and  evacuating  the  stone  by  this 
shorter  route. 

(1)  The  ordinary  median  operation  for  stone  may  be  extended  in 
the  following  manner :  On  the  finger  being  introduced  into  the  blad- 
der as  for  digital  exploration  by  perineal  urethrotomy,  the  membra- 
nous urethra  may  be  opened  up  by  passing  a  curved  probe-pointed 
bistoury  into  it,  with  the  edge  directed  toward  the  operator,  from  the 
wound ;  in  this  incision  may  be  included  more  or  less  of  the  entire 
thickness  of  the  perineum.  A  further  extension  is  made  by  passing 
the  curved  probe-pointed  bistoury  by  the  side  of  the  finger  well  into 
the  bladder.  The  edge  is  turned  toward  the  rectum,  and  the  floor  of 
the  prostate  is  divided  from  within  outwards,  commencing  in  the  de- 
pression which  more  or  less  exists  at  the  entrance  to  the  urethra. 
The  incision  thus  made  may  be  extended  downward  to  the  capsule 
by  the  firm  pressure  of  the  finger.  In  this  way  as  free  an  opening 
into  the  bladder  may  be  made  in  the  median  line  of  the  body  as  by  a 
lateral  lithotomy,  and  with  no  risk  of  causing  hemorrhage.  I  believe 
this  will  be  found  a  simple  and  safe  way  of  opening  the  bladder  for 
the  removal  of  stones,  which,  without  these  modifications,  could  only 
be  effected  by  either  lateral  or  supra-pubic  cystotomy.  Further,  it 
provides  for  an  incontinent  flow  of  urine  from  the  bladder,  which 
usually  continues  for  some  days. 

(2)  The  second  method  of  utilizing  median  urethrotomy  for  the 
removal  of  stone  from  the  bladder  consists  in  breaking  the  stones  into 
such  fragments  as  will  permit  of  their  withdrawal  without  any  exten- 
sion of  the  ordinary  incision.  Perineal  lithotrity,  as  this  operation 
may  be  called,  has  been  referred  to  by  Dr.  Goiiley,^®  of  New  York,  in 
the  following  words:  "The  name  of  perineal  lithotrity  was  given 
in  1862  by  Professor  Dolbeau,''  of  Paris,  to  an  operation  completed 
in  one  sitting,  by  which  the  membranous  portion  of  the  urethra 
is  opened,  the  prostate  and  neck  of  the  bladder  dilated  instead  of 
being  cut,  and  a  large  stone  crushed,  and  the  fragments  immediately 
extracted." 

The  pulverization  of  the  stone  is  here  effected  by  crushing  forceps, 
straight  and  curved  (Figs.  61  and  62)  which  can  be  passed  into  the 
bladder  through  a  perineal  urethrotomy  admitting  the  index  finger 
as  for  digital  exploration.  These  forceps  are  provided  with  a  cutting 
rib  within  the  blades.  The  more  powerful  instruments  are  fitted  with 
a  movable  screw  on  the  handle.  The  fragments  may  subsequently 
be  withdrawn  by  asi^irator  catheters  passed  through  the  wound,  or 
even  by  the  forceps.  If  care  is  taken  to  make  the  perineal  wound  cor- 
respond in  size  with  the  evacuating  catheters  there  is  no  difficulty  in 
Vol.  I.— 20 


306 


HAERISON — DISEASES  OF  THE  BLADDER. 


keeping  the  bladder  distended  with  fluid  during  the  necessary  manip- 
ulations. 

One  of  the  severest  tests  to  which  I  have  seen  these  crushing  for- 
ceps put  to  was  in  the  case  of  a  large  cystine  calculus  removed  by  Mr. 


Fig.  61.— straight  Crushing  Forceps. 

Heycock  at  St.  Peter's  Hospital  in  May,  1894,  by  perineal  lithotrity. 
It  weighed  over  two  ounces.  The  tough,  waxy  nature  of  the  stone 
would  have  resisted  the  most  powerful  lithotrite  and  it  was  with  some 
difficulty  that  the  forceps  reduced  it  to  such  pieces  as  were  remova- 
ble by  this  route.     The  patient  made  a  good  recovery. 

I  have  selected  this  method  in  twelve  instances  out  of  over  400 
stone  cases  requiring  operation,  and  have  so  far  had  no  deaths  follow- 
ing it.  The  chief  points  in  its  favor  are  these :  (1)  It  enables  the 
operator  to  crush  and  evacuate  large  stones  in  a  short  space  of  time. 
(2)  It  is  attended  with  a  very  small  risk  to  life  as  compared  with  other 
operations  where  any  cutting  is  done,  such  as  lateral  or  suprapubic 
lithotomy,  and  is  well  adapted  to  old  and  feeble  subjects.  In  a  re- 
cent address,  Mr.  Swinford  Edwards'""  shows  that  the  latter  operation 
for  large  stones  has  a  mortality  somewhere  about  fifty 
per  cent.  (3)  It  permits  the  operator  to  wash  out  the 
bladder  and  any  pouches  connected  with  it  more 
effectually  than  by  the  urethra,  as  the  route  is  shorter 


Fig.  62.— Curved  Crushing  Forceps. 

and  the  evacuating  catheters  employed  are  of  much  larger  calibre. 
(4)  The  surgeon  can  usually  ascertain,  either  by  exploration  with  the 
finger  or  by  the  introduction  of  forceps  into  the  bladder,  that  the  vis- 
cus  is  cleared  of  all  debris.  (5)  It  enables  the  surgeon  to  deal  with 
certain  forms  of  prostatic  outgrowth  and  obstruction  complicated  with 


LITHOTOMY. 


307 


atony  of  the  bladder  in  sucL.  a  way  as  to  secure  not  only  tlie  removal 
of  the  stone,  but  the  restoration  of  the  function  of  micturition,  (6)  By 
the  subsequent  introduction  and  temporary  retention  of  a  soft  rubber 
drainage-tube,  states  of  cystitis  due  to  the  retention  of  urine  in 
pouches  and  depressions  in  the  bladder  wall  are  either  entirely  cured 
or  are  permanently  improved.  To  lock  up  unhealthy  am- 
moniacal  urine  in  a  bladder  that  cannot  properly  empty 
itself  after  a  lithotrity,  is  to  court  the  formation  or  recur- 
rence of  a  phosphatic  stone.  Hence  the  operation  is  well 
suited  to  some  cases  of  recurrent  calculus.  I  have  never 
known  the  wound  to  remain  unhealed,  except  in  those  in- 
stances where,  for  some  reason  or  other,  it  has"  been  desired 
to  construct  a  low-level  urethra. 

It  is  well  adapted  for  some  cases  of  stone  in  the  blad- 
der complicated  with  stricture  in  the  deep  urethra,  as  it 
enables  the  surgeon  to  deal  with  both  at  the  same  time. 
Nor  does  it  expose  the  patient  to  the  risk  which  may  be 
attendant  where  lithotrity  is  performed  with  a  weakened 
or  permanently  damaged  urethra,  as  illustrated  in  a  pre- 
ceding case.  Dr.  Bangs'"  records  a  case  of  recurrent  cal- 
culus of  much  interest,  where  dilatation  of  the  prostatic 
urethra  through  a  perineal  opening  was  effected,  for  the 
purpose  of  crushing  and  extracting  the  stone,  by  means  of 
Dolbeau's  dilator  (Fig.  63) .  The  instrument  is  expanded 
by  a  screw  arrangement  at  the  handle.  Commenting  upon 
this  patient.  Dr.  Bangs  observes : 

"  He  is  able  to  urinate  spontaneously  standing,  and  in 
a  full  stream,  and  when  the  catheter  is  passed  once  a  day 
for  the  purpose  of  washing  there  is  only  one,  and  rarely 
two,  ounces  of  residual  urine.  This  improvement  in  his 
power  of  urination  is  the  result  to  which  I  wish  to  call 
special  attention.  During  the  first  operation  (supra-pubic 
cystotomy)  the  apparent  obstacles  to  urination,  namely, 
the  prostatic  outgrowths  and  the  calculus,  had  been  re- 
moved; and  after  the  oj^eration  the  bladder  had  been 
drained  as  long  and  kept  as  clean  as  after  the  second. 
But  there  was  very  little  spontaneous  urination,  and  the 
act  was  accomplished  with  a  hesitating,  dribbling  stream, 
leaving  a  notable  quantity  of  residual  urine  to  decompose 
and  fret  an  already  irritable  bladder.  After  the  perineal  operation, 
however,  he  was  able  to  stand  up,  and  almost  entirely  empty  his 
bladder  in  a  strong,  full  stream,  with  every  sense  of  comfort.  An 
explanation  of  the  difference  in  the  result  must  be  sought  for,  and  I 


Fig.  63.— 
Dolbeau's 
Dilator. 


308  HAERISON — DISEASES  OF  THE  BLADDER. 

tliink  is  to  be  found  in  the  enormous  dilatation  to  whicli  tlie  prostatic 
urethra  was  subjected  in  the  perineal  operation.  This  fact  has,  I 
believe,  an  important  bearing  upon  the  many  failures  to  obtain  spon- 
taneous urination  after  prostatectomy." 

Stone  in  female  adults  and  children  is  comparatively  rare,  which  is 
probably  due  to  the  short  urethra  favoring  the  escape  of  a  calculus  at 
the  earUest  period  of  its  formation.  Concretions  on  foreign  bodies, 
such  as  hair-pins,  are  not  unfrequently  met  with,  and  the  possibility 
of  a  stony  mass  having  a  nucleus  of  this  kind  must  not  be  lost  sight 
of  in  connection  with  their  removal.  Instances  are  recorded  where 
the  jaws  of  the  lithotrite  became  entangled  in  wires  and  hair-pins, 
upon  which  a  phosphatic  deposit  had  taken  place,  during  attempts 
made  to  remove  the  foreign  body  in  this  manner. 

"Where  the  stone  is  not  large,  removal  may  be  undertaken  by  rapid 
dilatation  of  the  urethra  and  extraction  of  the  calculus  with  forceps. 
If  dilatation  is  extreme  more  or  less  permanent  incontinence  of  urine 
may  result,  a  condition  which  is  most  distressing  to  the  patient,  as 
it  is  not  easily  remedied.  As  indicating  the  extent  to  which  the  fe- 
male urethra  may  with  safety  be  dilated  for  the  purpose  either  of  ex- 
ploration or  of  extracting  a  stone,  the  following  passage  on  Dr. 
Ogston's  authority  may  be  quoted :  "  Simon's  statements  have  now 
been  verified  by  general  experience.  Hence,  since  the  average  diame- 
ter of  a  man's  right  index  finger  at  its  thickest  part  is  about  |  inch 
(1.8  cm.),  and  of  his  little  finger  |  inch,  it  may  be  stated  that  we  can 
safely  dilate  the  adult  urethra  so  as  to  admit  the  index  finger,  and  the 
child's  so  as  to  admit  the  little  finger."  '"  These  limits  should  not 
be  exceeded,  otherwise  a  risk  of  permanent  incontinence  is  incurred. 

In  the  case  of  large  stones,  which  cannot  be  included  within  the 
grip  of  the  lithotrite,  removal  has  been  effected  by  supra-pubic  or 
vaginal  lithotomy.  The  latter  operation  consists  in  opening  the  va- 
ginal wall  of  the  bladder  by  a  median  incision,  and,  after  extracting 
the  stone  by  forceps,  reuniting  the  edges  of  the  wound  by  sutures,  as 
is  done  for  vesico-vaginal  fistula,  as  described  by  Dr.  J.  C.  Warren."' 
Dr.  Galabin  has  recorded  a  case  where  by  this  operation  he  removed 
twelve  large  calculi  and  about  fiity  smaU  ones  from  the  bladder  of  a 
woman  aged  sixty-one.  The  wound  was  closed  by  silkworm-gut  su- 
tures, and  at  the  end  of  ten  days  union  was  complete.  '"*  Vaginal  lith- 
otomy has  been  almost  entirely  supplanted  by  lithotrity  and  the  high 
operation. 

Supra-Pubic  Cystotomy. 

The  revival  of  supra-pubic  cystotomy  is  in  a  large  measure  due 
to  the  observations  of  Garson,"'  the  practice  of  Petersen,"'  of  Kiel, 


SUPRA-PUBIC  CYSTOTOMY.  309 

and  the  advocacy  of  Sir  Henry  Thompson. '"  I  propose  to  refer  to  this 
operation  in  its  application  to  (1)  stone  in  the  bladder,  (2)  tumors 
and  growths,  including  hypertrophy  of  the  prostate  encroaching  upon 
the  interior  of  the  bladder,  (3)  foreign  bodies,  and  (4)  other  condi- 
tions requiring  the  inspection  of  the  interior  of  the  bladder  and 
drainage.  In  all  these  states,  subject  to  some  modifications,  it  has 
been  applied  with  success.  I  will,  first  of  all,  describe  the  method  of 
operating. 

The  patient  may  be  placed  either  recumbent,  as  for  an  abdominal 
operation,  or  with  the  pelvis  elevated,  as  in  what  is  known  as  Tren- 
delenburg's position.  In  the  former  case  it  was  usual  to  distend  the 
bladder  with  some  ounces  of  water,  and  likewise  the  rectum  by 
means  of  an  elastic  air-bag  capable  of  inflation;  the  object  of  this 
being  not  only  to  make  the  outline  of  the  viscus  more  prominent  but 
to  increase,  as  it  is  alleged,  the  space  immediately  above  the  pubes 
where  the  bladder  is  uncovered  with  peritoneum.  Such  measures  are 
not  now  insisted  upon,  beyond  retaining  a  few  ounces  of  water,  hardly 
amounting  to  distention.  The  rectum  bag,  in  the  majority  of  in- 
stances, is  unnecessary,  unless  it  is  used  with  the  object  of  enabling 
the  operator,  after  the  bladder  has  been  opened,  to  reach  the  poste- 
rior wall  with  his  finger,  which  in  corpulent  persons  would  otherwise 
be  impossible.  I  much  doubt  whether  the  area  above  the  pubes,  un- 
covered by  peritonseum,  is  increased  by  the  combined  distention  of 
the  bladder  and  rectum,  as  first  proposed,  unless  it  is  practised  with 
such  an  amount  of  force  as  to  render  the  proceeding,  in  the  case  of  a 
weak  bladder,  somewhat  hazardous.  Rupture  of  the  bladder  as  well 
as  the  bowel  has  been  caused  in  this  way.  A  patient  with  a  stricture 
and  a  distended  bladder  was  placed  on  the  operating  table  in  Belle- 
vue  Hospital,  New  York,  for  the  purpose  of  having  the  stricture  re- 
lieved."^ While  struggling  under  ether  the  abdominal  tumor  sud- 
denly disappeared,  and  the  former  area  of  dulness  became  tympanitic. 
At  a  post-mortem  examination  the  bladder  was  found  ruptured,  with- 
out ulceration  or  other  alteration.  No  doubt  the  distention  in  this 
case  was  considerable,  as  two  quarts  and  a  liaK  of  bloody  fluid  were 
found  in  the  abdomen.  Air  has  been  substituted  for  water  in  distend- 
ing the  bladder,  on  the  grounds  that  it  is  less  likely  to  do  injury  and 
is  calculated  to  render  the  viscus  more  prominent.  I  do  not  think 
there  is  much  in  this,  and  if  the  intestines  happened  to  be  flatulent 
there  might  be  some  difficulty  in  distinguishing  the  viscera.  The 
bladder  having  been  washed  out,  a  few  ounces  of  boracic  solution  be- 
ing left  within  it,  secured  there  by  a  ligature  round  the  penis,  and 
the  i)ubes  shaved,  the  operation  may  now  be  proceeded  with.  When 
Trendelenburg's  position  is  selected,  the  patient  is  placed  as  shown  in 


310 


HAEEISON — DISEASES   OE  THE  BLADDEK. 


the  illustration  (Fig.  64) . "'  It  lias  some  advantages,  as  tlie  intestinal 
pressure  tends  to  gravitate  toward  tlie  thorax  and  away  from  tlie 
wound.     Tlie  operator  then  proceeds  to  open  the  bladder,  by  either 


Fig.  64.— Trendelenburg's  Position  for  Supra-pubic  Lithotomy. 

the  vertical  or  transverse  incision.  In  the  former  case,  standing  on 
the  left  side  of  the  patient,  he  commences  immediately  above  the  bony 
margin  of  the  pubis,  and  prolongs  his  incision  for  about  two  inches 
toward  the  umbilicus  in  the  median  line.  This  should  be  carried 
down  to  the  intermuscular  interval  which  is  to  be  opened.  On  this 
being  accomplished,  the  index  finger  should  hook  up  the  tissues 
above  the  upper  portion  of  this  dissection,  so  as  to  draw  the  perito- 
neal reflection  toward  the  umbiUcus.  I  have  in  this  way  seldom  seen 
the  peritoneum,  or  even  been  conscious  of  its  existence.  There  is 
generally  some  fat  and  cellular  tissue  between  the  muscle  and  the 
bladder,  which  can  be  scraped  away  with  the  finger,  when  the  ante- 
rior surface  of  the  bladder  will  be  seen.  Care  should  be  taken  to  avoid 
or  to  tie  any  large  veins  that  may  be  met  with,  as  they  sometimes 
bleed  freely,  and  have  been  known  in  elderly  persons  to  cause  secon- 
dary hemorrhage.  It  is  a  good  plan  to  pass  a  handled  needle,  with 
a  stout  silk  thread,  through  the  bladder  wall  before  it  is  opened  with 
the  knife,  so  as  to  secure  it.  The  knife  should  be  inserted  into  the 
bladder  in  the  median  line,  and  the  incision  made  in  an  upward  di- 
rection so  as  to  admit  the  index  finger;  when  this  is  accomplished  it 
can  be  readily  extended  according  to  circumstances.  I  prefer  holding 
the  bladder  wound  open  by  a  stout  silk  suture  on  either  side  rather 
than  by  forceps.  The  latter  are  more  likely  to  cause  a  rough  cicatrix 
afterward,  which  is  a  matter  of  importance.  I  have  seen  a  little 
trouble  arise  by  the  surgeon  merely  puncturing  the  bladder  with  his 
knife,  thus  allowing  the  water  to  escape  and  the  viscus  to  become  ab- 


SUPRA-PUBIC  CYSTOTOMY.  311 

solutely  flaccid.  Wlien,  for  this  reason,  tliere  is  difficulty  in  finding 
the  wound  again,  as  is  sometimes  the  case,  a  metal  bulbous-ended 
bougie  should  be  passed  into  the  bladder,  when  the  opening  is  readily 
discovered. 

When  it  is  desirable  to  open  the  bladder  by  a  transverse  incision, 
the  opening  should  be  made  immediately  above,  and  parallel  with, 
the  line  of  the  pubis,  which  involves  the  division  of  some  portion  of 
the  tendons  of  the  recti  muscles.  Trendelenburg  recommends  that 
the  mucous  membrane  of  the  bladder  should  be  connected  with  the 
skin  by  means  of  temporary  sutures.  This  incision  affords  a  greater 
area  of  surface  for  doing  what  is  necessary,  and  is  recommended  in 
some  cases  of  tubercular  ulceration  of  the  bladder  requiring  local 
treatment,  for  plastic  operations,  for  removing  extensive  growths,  and 
for  the  direct  inspection  and  manipulation  of  the  orifice  of  the  ure- 
ters. I  have  never  had  occasion  to  adopt  it,  except  to  a  limited  ex- 
tent in  conjunction  with  the  ordinary  median  incision,  as  first  de- 
scribed. It  is  stated  that  the  transverse  incision  is  more  liable  to  be 
followed  by  a  ventral  hernia  than  the  other. 

The  bladder  having  been  opened,  I  will  now  notice  the  variations 
necessary  in  accordance  with  the  different  requirements  and  the  sub- 
sequent management  of  the  wound.  If  there  is  a  stone  it  is  usually 
at  once  felt  with  the  finger,  when  it  can  be  withdrawn  with  a  pair  of 
straight  or  curved  forceps.  Care  should  be  taken  not  to  damage  the 
sides  of  the  wound.  Should  there  be  a  growth  or  prostatic  enlarge- 
ment encroaching  on  the  interior  of  the  bladder,  it  can  generally  be 
felt  by  the  finger.  It  can  also  be  inspected  by  opaque  glass  or  vul- 
canite specula  of  different  sizes  introduced  through  the  wound  as  de- 
scribed by  Mr.  Hurry  Fenwick  ''°  in  conjunction  with  the  reflection 
from  the  electric  light.  The  latter  plan  is  an  excellent  one,  not  only 
so  far  as  seeing  the  growth  is  concerned,  but  also  in  assisting  mate- 
rially toward  its  removal.  For  keeping  the  bladder  open  to  inspec- 
tion, and  at  the  same  time  occupying  very  little  room,  if  the  viscus  is 
of  fair  capacity,  Watson's  spring  wire  speculum  will  be  found  useful. 
Various  kinds  of  forceps  for  twisting  off  pieces  of  growth  should  be 
at  hand.  This,  I  believe,  is  the  best  method  of  removing  masses  of 
hypertrophied  prostate  or  other  growths.  Some  scoops  and  an  enu- 
cleator  hook  should  also  be  in  readiness.  In  this  way,  and  by 
other  modifications  which  will  occur  to  the  practical  surgeon,  intra- 
vesical growths  may  be  removed  with  a  preciseness  which  previous 
to  the  introduction  of  supra-pubic  cystotomy,  the  use  of  specula, 
and  proper  forceps  and  light,  was  generally  unattainable.  Where 
there  is  bleeding  the  vessels  may  readily  be  touched  with  some 
styi)tic,   such  as  iron,  turpentine,  or  the  wires  of  a  galvanic  cau- 


Br2  HARRISON — DISEASES  OP  THE  BLADDER. 

tery ;  whereas  if  tlie  oozing  is  general  tlie  surface  may  be  exposed  to 
tlie  action  of  liot  water  and  liazeline  injected  through  the  wound. 
When  drainage  alone  is  required,  supra-pubic  cystotomy  has  been  re- 
sorted to  with  much  advantage. 

Mr.  Lawson  Tait'"  has  recently  described  a  method  of  operating 
by  a  process  of  drawing  up  the  bladder,  which  he  describes  as  simple 
and  safe.  From  some  experience  of  supra-pubic  cystotomy  under 
almost  all  conditions  for  which  it  is  applicable,  I  think  the  less  we 
alter  the  relations  of  the  bladder  in  removing  anything  from  its  inte- 
rior the  better.  There  is  no  necessity  for  either  pushing  it  up  from 
the  pelvic  outlet  or  disconnecting  it  from  its  peritoneal  attachments, 
and  I  have  never  found  the  least  difficulty  in  opening  it  either  for 
stone  or  tumor  in  the  way  mentioned. 

The  object  of  cystotomy  having  been  accomplished,  the  question 
arises  as  to  what  is  best  to  be  done  to  secure  the  rapid  healing  of  the 
wound,  should  this  be  required.  Cases  have  been  recorded  where  the 
suturing  of  the  bladder  and  superficial  wound  has  been  followed  by 
primary  union,  but  they  are  rare ;  on  the  other  hand,  instances  are 
narrated  where  not  only  have  these  attempts  failed  but  inflamma- 
tion had  followed  by  the  confinement  of  urine  in  the  prevesical  space. 
My  belief  is,  as  matters  stand  at  present,  that  a  medium  course  is 
best.  With  this  object  I  leave  the  bladder  opening  alone  and  close 
the  superficial  wound  to  some  extent,  but  allow  space  for  the  use 
of  what  is  generally  known  as  Guyon's  double  drainage-tube.  This 
is  really  two  rubber  catheters  connected  together,  which  give  access 
either  way  either  to  antiseptic  lotion  or  urine,  the  latter  being  received 
in  a  bottle  by  the  patient's  side.  The  dressing  is  then  completed  by 
gauze,  wood-wool  pads,  and  an  abdominal  many-tailed  bandage.  If 
for  any  reason  I  were  disposed  to  attempt  to  obtain  primary  union  by 
complete  suture  of  the  bladder  and  superficial  wound,  I  should  put 
into  the  bladder  a  perineal  drainage-tube.  One  word  in  connection 
with  the  use  of  bladder  sutures  in  these  and  similar  operations :  if  they 
are  put  in,  care  should  be  taken  that  they  are  completely  removed. 
I  have  known  two  instances  where  these  bodies  gave  much  trouble 
subsequently  in  causing  cystitis  and  the  deposit  of  a  phosphatic 
stone.  Mr.  Jordan  Lloyd  records  an  instance  where  a  calculus 
formed  upon  a  nucleus  of  this  nature  was  expelled ^er  urethram.^^''  If 
an  attempt  is  made  to  close  the  bladder  wound  by  suture  with  the  ob- 
ject of  obtaining  primary  union,  the  accuracy  of  approximation  should 
be  tested  by  the  injection  of  water  into  the  viscus. 

In  cases  where  there  has  been  difficulty  in  removing  a  large  stone 
through  the  supra-pubic  incision,  much  damage  to  the  bladder  from 
ineffectual  attempts  to  extract  might  have  been  averted  by  making, 


StJPRA-PtJBIC  CYSTOTOMY.  313 

in  addition,  an  incision  as  for  median  cystotomy,  by  wliich  the  position 
of  tlie  stone  could  be  altered  with  the  finger  from  the  perineal  wound, 
while  the  forceps  were  applied  through  the  supra-pubic  opening. 

Supra-pubic  cystotomy  has  proved  of  much  value  in  the  treatment 
of  stones  where  the  operator  was  of  opinion  that  they  were  too  large 
for  removal  by  crushing  or  in  any  other  way.  It  is  impossible  to 
define  by  measurements  what  is  meant  by  a  very  large  stone.  The 
term  must  be  regarded  somewhat  as  a  relative  one,  in  which  the  ex- 
perience of  the  operator,  the  state  of  the  urethra,  the  size  of  the  pros- 
tate, and  the  condition  of  the  bladder  have  to  be  taken  into  consider- 
ation. An  ounce-and-a-half  stone,  for  instance,  complicated  with  an 
obstructive  prostate,  might,  in  the  opinion  of  the  operator,  require 
a  supra-pubic  opening ;  whereas,  if  it  had  not  been  so  complicated, 
a  calculus  twice  this  size,  or  even  larger,  could  be  dealt  with  by 
crushing.  Again,  the  probable  composition  of  the  stone,  whether  a 
hard  or  a  soft  one,  will  influence  the  decision  of  the  surgeon.  In  the 
same  manner  a  conclusion  may  be  arrived  at  in  the  case  of  male  chil- 
dren ;  the  size  and  nature  of  the  calculus,  coupled  with  the  practi- 
tioner's own  experience  in  these  operations,  will  determine  whether 
crushing  or  cutting  should  be  undertaken. 

Sacculated  stones,  or  the  possibility  of  such  a  condition,  would 
point  to  the  selection  of  the  high  operation.  Mr.  Vincent  Jackson  "^ 
reports  an  apt  illustration  bearing  upon  this  point,  where  supra- 
pubic lithotomy  was  successfully  performed  for  the  removal  of  a 
lithic-acid  calculus,  weighing  over  fifty  grains,  which  was  fixed  in  a 
sacculus  at  the  base  of  the  bladder.  Removal  had  previously  been 
attempted  by  perineal  lithotomy. 

Where  stone  in  the  bladder  is  complicated  with  an  enlarged  pros- 
tate, and  the  patient  is  more  or  less  dependent  on  the  catheter  by 
reason  of  atony,  there  are  good  grounds  for  the  selection  of  supra- 
pubic cystotomy.  By  this  means  not  only  may  the  stone  as  well  as 
the  obstruction  be  removed,  but  the  function  of  the  bladder  may  be  re- 
stored. It  is  in  cases  of  this  kind,  where  the  patient  is,  or  becomes, 
absolutely  dependent  on  the  use  of  the  catheter  after  lithotrity,  that  cal- 
culous recurrence  so  frequently  takes  place.  There  can  be  no  doubt 
that  a  complete  power  of  contraction  and  evacuation  is  an  important 
consideration  in  the  selection  of  lithotrity.  "When  performing  supra- 
pubic cystotomy  it  is  well  to  see  that  the  external  meatus  of  the  ure- 
thra is  not  unnaturally  limited,  and  if  this  is  the  case  it  should  be  di- 
vided. I  have  known  an  instance  where  such  an  obstruction  retarded 
the  healing  of  the  supra-pubic  incision,  in  the  same  way  that  an 
urethral  stricture  does,  and  where  before  the  wound  healed  it  was 
necessary  to  divide  the  meatus  with  some  freedom. 


314  HARRISON — DISEASES  OF  THE  BLADDER. 

Instances  are  occasionally  met  with  where,  for  some  reason,  the 
supra-pubic  opening  does  not  close  as  rapidly  as  could  be  desired, 
and  a  more  or  less  troublesome  fistula  results.  It  may  merely  be  a 
case  of  delay,  where  healing  can  be  promoted  by  the  use  of  nitrate  of 
silver,  the  wire  of  the  cautery,  or  even  the  simple  expedient,  if  the 
hole  is  a  small  one,  of  requiring  the  patient  to  exercise  firm  pressure 
over  it  with  the  finger  each  time  urine  is  voluntarily  passed.  The 
retention  of  a  soft  catheter  in  the  urethra  for  a  few  days,  or  the  fre- 
quent passing  of  a  catheter,  are  also  expedients  which  have  proved 
successful.  In  two  instances  where  the  fistula  looked  as  if  it  were 
going  to  be  permanent  I  passed  a  grooved  staff  into  the  bladder, 
punctured  the  membranous  urethra,  and  put  a  drainage-tube  into 
the  bladder.  By  incontinently  and  continuously  draining  the  urine  in 
this  way  for  some  days,  the  fistula  healed,  as  did  subsequently  the 
perineal  puncture  on  the  Avithdrawal  of  the  drainage-tube.  This  plan 
has  also  been  adopted  as  a  primary  part  of  the  operation  for  supra- 
pubic cystotomy.  The  drainage  thus  provided  has  enabled  the  sur- 
geon to  close  the  anterior  wound  by  superficial  and  deep  sutures,  and 
primary  union  has  in  this  way  been  obtained. 

The  supra-pubic  operation  has  been  used  in  cases  of  stone  in 
women  with  advantage,  and  also  in  both  sexes  for  the  removal  of 
some  calculi,  formed  on  such  irregular  foreign  bodies  as  hair-pins 
and  wires  which  have  been  introduced  into  the  urethra.  Under  the 
latter  circumstances,  lithotrity  would  be  out  of  the  question,  as  such 
attempts  to  extract,  after  breaking  down  the  phosphatic  mass  covering 
the  bodies,  have  been  attended  with  serious  and  fatal  consequences. 
By  a  supra-pubic  incision  less  difiiculty  and  risk  may  be  anticipated, 
as  should  it  be  necessary  the  nucleus  may  be  divided  by  a  pair  of 
cutting  pliers  or  bone-forceps.  The  bladder  can  in  women  be  kept 
moderately  distended  with  water  by  the  pressure  of  a  finger  on  the 
line  of  the  urethra  until  it  is  opened  from  the  front.  The  high  opera- 
tion has  been  utilized  for  plastic  operations,  as  in  the  case  of  some 
varieties  of  vesico-vaginal  fistulse. 

The  scar  left  after  supra-pubic  cystotomy  sometimes  causes  in- 
convenience and  spasms  by  preventing  the  bladder  contracting  down 
as  the  contents  of  the  viscus  escape.  Where  the  scar  tissue  is  very 
thick  and  hard  the  annoyance  is  sometimes  considerable,  but  in  other 
cases  matters  gradually  adapt  themselves. 

The  Recurrence  of  Stone  After  Operation. 

I  will  now  pass  on  to  consider  one  of  the  most  important  points 
in  connection  with  the  history  of  stone  in  the  bladder ;  I  refer  more 


EECUEEENCE   OF  STONE  AFTER  OPERATION,  315 

particularly  to  those  instances  where  recurrence  takes  place  after 
operation.  It  will  be  remembered  by  those  who  have  watched  the 
course  events  have  taken,  more  especially  in  connection  with  the  re- 
moval of  stone  by  crushing,  that  though  this  operation  had  made 
considerable  progress  in  many  of  its  details  a  few  years  ago,  the  views 
of  surgeons  were  by  no  means  unanimous  as  to  its  great  superiority 
over  lithotomy,  except  in  the  case  of  comparatively  small  stones  in 
bladders  that  were  not  otherwise  disordered.  In  a  discussion  '"  which 
took  place  about  the  time  when  the  old  method  of  operating  by  nu- 
merous sittings  was  giving  place  to  Bigelow's  procedure,  it  was  evi- 
dent that  lithotrity  was  not  growing  in  favor.  This  was  due  not  to 
any  excessive  mortality,  or  to  any  special  difficulties  connected  with 
the  operation,  but  to  the  fact  that,  even  in  the  most  competent  hands, 
it  failed  in  a  considerable  proportion  of  instances  to  give  immunity 
from  recurrence.  Nor  was  there  any  desire  to  exaggerate  this  fact, 
for,  as  Sir  James  Paget  observed  in  the  discussion  referr-ed  to,  the 
proportion  of  relapses  would  have  been  considerably  increased  if  the 
period  of  probation  subsequent  to  the  operation  had  been  extended 
from  a  few  weeks  to  at  least  a  year.  Speaking  on  the  same  occasion, 
Mr.  Cadge  remarked  to  the  ejffect  that  it  would  be  necessary  to  include 
the  results  of  lithotrity  under  three  headings,  namely,  those  persons 
who  were  cured,  those  who  died,  and  those  who  did  not  eventually 
recover.  It  was  hoped  that  the  new  method  of  operating,  which  was 
then  coming  into  vogue,  by  securing  a  more  rapid  and  complete  evac- 
uation of  all  fragments  from  the  bladder,  would  materially  mitigate 
this  acknowledged  defect.  Turning  to  the  address  of  Mr.  Cadge 
(1886) ,  one  of  my  predecessors  in  the  Hunterian  Chair  at  the  Royal 
College  of  Surgeons,  which  was  delivered  seven  years  after  Bigelow's 
operation  had  been  introduced,  and  after  a  fair  trial  of  the  new  opera- 
tion in  a  sphere  presenting  almost  unique  opportunities  for  observa- 
tion, we  find  he  referred  to  this  point  in  the  following  words :  "  Al- 
though the  immediate  and  direct  mortality  of  lithotrity  is  small,  the 
recurrence  of  stone  is  lamentably  frequent.  In  my  omti  list  of  133 
cases  there  were  18  in  which  recurrences  one  or  more  times  took 
place,  being  about  one  in  seven.  Sir  Henry  Thompson,  with  a  much 
larger  number  of  cases,  gives  about  the  same  proportion.  I  am  dis- 
posed, however,  to  infer  that  recurrence  is  more  frequent  than  this." 
I  am  not  aware  that  the  accuracy  of  this  statement  has  been  chal- 
lenged or  that  anything  has  since  arisen  to  question  its  application 
to  what  now  exists.  If  my  own  experience  had  not  furnished  me  with 
a  text,  I  should  have  found  it  in  these  v/eighty  testimonies.  In  pro- 
ceeding to  consider  the  circumstances  under  which  these  recurrences 
take  place,  I  need  hardly  observe  it  is  not  with  an  intention  of  dis- 


316 


HAERISON — DISEASES  OF  THE  BLADDER. 


paraging  litliotrity  or  of  upliolding  litliotomy,  but  witli  the  object  of 
finding  a  remedy  for  defects  wliich  cannot  fail  to  be  admitted  by  a 
candid  observer.  The  due  recognition  of  the  considerable  mortality 
that  formerly  prevailed,  and  its  probable  cause,  doubtless  led  Bigelow 


Fig.  65.— Ideal  Bladder  Containing  a  Calculus  CSchematic). 

in  the  direction  of  making  such  improvements  as  almost  entirely  to 
remove  at  one  sweep  the  chief  risk  connected  with  the  performance  of 
lithotrity. 

From  a  lay  point  of  view  the  recurrence  of  stone  after  it  has  once 
been  supposed  to  be  removed  is  usually  regarded  as  evidence  that  the 
operation  performed  was  in  some  way  or  other  defective.  This  con- 
clusion is  based  on  an  idea  that  a  calculus  in  the  bladder  always 


Fig.  66.— Actual  Condition  Possibly  Present  in  a  Bladder  Containing  a  Calculus  (Schematic). 

bears  some  resemblance  to  a  stone  in  a  box,  and  that  consequently 
the  conditions  associated  with  its  removal  are  of  a  mechanical  and 
constant  nature.  A  slight  acquaintance  with  the  circumstances  at- 
tendant upon  operations  for  stone,  combined  with  a  knowledge  of  the 


RECURRENCE  OF  STONE  AFTER  OPERATION.  317 

pathological  changes  the  bladder  often  undergoes,  is  sufficient  to 
show  that  such  a  simile  is  of  limited  application,  and  that  other  con- 
ditions often  coexist  which  are  not  sufficiently  taken  into  account. 
The  contrast  between  the  ideal  (Fig.  65)  and  the  real  bladder 
(Fig.  66)  containing  a  stone  may,  without  exaggeration,  in  some  el- 
derly persons,  be  approximately  shown  in  the  sketches  I  have 
drawn.  These  may  also  be  useful  in  indicating  some  of  the  different 
circumstances  under  which  washing  out  of  the  bladder  has  to  be 
undertaken. 

Condition  of  Recurrence. — There  are  at  least  three  forms  or  states 
under  which  recurrence  takes  place :  (1)  as  connected  with  an  imper- 
fect removal,  where  portions  of,  or  even  whole  stones  are  left  behind; 
(2)  the  persistence  of  conditions  favorable  to  the  production  of  stone 
which  are  in  no  way  influenced  by  the  mere  removal  from  the  bladder 
of  what  has  already  been  produced ;  and  (3)  the  development  of  con- 
ditions favorable  to  the  production  of  stone,  conditions  which  had  no 
existence  prior  to  the  removal  of  the  original  calculus.  It  will  be 
necessary  to  expand  and  illustrate  these  several  headings. 

(1)  That  imperfect  removal  is  an  antecedent  of  recurrence  both  in 
Kthotomy  and  lithotrity,  rare  with  the  former  and  more  frequent  with 
the  latter,  is  a  fact  which  is  generally  admitted.  Putting  aside  those 
instances  which  may  be  due  to  somewhat  hasty  and  imperfect  meth- 
ods of  examination  at  the  time  of  operation,  I  will  proceed  to  notice 
some  of  the  conditions  where  exceptional  obstacles  to  complete  re- 
moval are  interposed,  which  may  thus  be  regarded  as  contributing 
causes  of  recurrence.  These  will  be  found  to  have  reference  to  the 
shape  of  the  bladder  or  the  prostate,  rather  than  to  anything  con- 
nected with  the  size  or  the  form  of  the  stone.  Where  a  stone  lies  in  a 
normally  disposed  bladder  the  probabilities  of  any  recurrence  taking 
place  after  removal  are  extremely  remote ;  for  if  the  operator  were 
to  succeed  in  removing  everything  but  the  smallest  particles,  the  local 
conditions  are  such  as  almost  to  insure  their  spontaneous  discharge. 
The  success  of  lithotrity  in  early  life,  and  the  gradual  increase  in  the 
number  of  recurrences  as  age  advances,  coincident  with  changes  in 
the  shape  of  the  prostate  and  the  posterior  waU  of  the  bladder,  afford 
evidence  of  this.  These  contributing  alterations  in  the  shape  of  the 
viscus,  as  forming  traps  for  stone  or  fragments,  may  briefly  be  no- 
ticed. 

Reference  to  specimens  of  pouched  and  distorted  bladders  wiU  be 
sufficient  to  indicate  more  forcibly  than  words  the  obstacles  that  are 
sometimes  i)laced  in  the  way  of  the  operator  endeavoring  to  remove 
all  traces  of  stone  when  it  happens  under  such  conditions.  A  stone 
in  the  mouth  of  a  pouch  or  of  a  sacculus  may  sometimes  act  as  a 


318  HAERISON— DISEASES  OP  THE  BLADDER. 

cork  (Fig.  66) ,  and  permit,  after  its  removal  by  tlie  lithotrite,  of  tlie 
escape  of  a  second  stone  into  tlie  general  cavity  of  tlie  bladder  by 
either  muscular  action  or  accidental  extrusion.  This,  I  believe,  hap- 
pened in  a  case  where  I  removed  a  calculus  from  an  apparent  healthy 
bladder  in  a  young  adult  male.  Shortly  after  this  was  done,  symp- 
toms of  stone,  without  any  evidence  of  renal  colic,  suddenly  returned 
and  another  calculus  was  removed  by  a  supra-pubic  operation.  At  the 
time  of  the  first  operation  I  satisfied  myself,  as  far  as  it  was  possible, 
that  the  bladder  was  clear,  and  I  had  no  reason  to  suspect  otherwise. 
Again  it  has  occurred  that  a  flat  shell  of  calculus  after  lithotrity  has 
remained  concealed  under  a  projecting  bar  of  prostatic  tissue  and 
subsequently  getting  on  its  edge  has  excited  symptoms  of  most  acute 
irritation.  This  has  been  the  more  pronounced  when  the  mischief 
has  occurred  in  a  bladder  which  is  more  or  less  dependent  on  the  use 
of  the  catheter.  Such  abnormalities  explain  obstacles  in  the  way  of 
complete  evacuation  which,  though  we  may  be  cognizant  of  them,  are 
difficult  to  provide  against. 

(2)  Proceeding  to  the  second  heading,  I  have  observed  that  the 
mere  removal  of  a  stone  from  the  bladder  by  a  mechanical  process  in 
no  way  imj)lies  that  the  conditions  which  led  to  the  primary  forma- 
tion have  necessarily  been  altered  or  interfered  with.  Take,  for  in- 
stance, those  more  obvious  illustrations  of  stone  formation  which  are 
sometimes  seen  in  persons  with  paralyzed  bladders,  as  from  fracture 
of  the  spine  where  a  series  of  these  concretions  form  with  remarkable 
rapidity,  or  in  gouty  subjects  who  excrete  large  quantities  of  lithic 
acid  crystals.  In  the  former  case,  so  long  as  we  have  alkaline  urine 
and  shreds  of  cast-off  mucus,  we  have  all  the  conditions  necessary  for 
the  production  of  phosphatic  stones  ad  infinitum.  So  with  the  concre- 
tions of  uric  acid  which  primarily  form  as  renal  calculi  in  the  tubular 
portions  of  the  kidneys.  While  there  is  a  supply  of  these  in  conjunc- 
tion with  their  necessary  crystalline  deposit,  the  process  of  stone  for- 
mation may  readily  be  repeated,  and  as  age  proceeds  and  the  prostate 
enlarges  a  condition  is  superadded  favorable  to  the  collection  and  con- 
cretion of  lithic  acid  which  did  not  previously  exist.  Hence  I  be- 
lieve the  greater  frequency  of  stone  at  advanced  periods  of  life  is 
accounted  for,  not  only  for  the  reason  that  the  facilities  for  making 
lithic  acid  are  frequently  increased,  but  because  the  latter  is  often 
discharged  from  the  urinary  apparatus  under  circumstances  of  greater 
difficulty.  If  a  person,  for  instance,  has  a  stone  in  his  bladder  and 
also  others  in  his  kidney,  or  in  course  of  formation  there,  while  con- 
currently he  has  developed  an  enlarged  prostrate,  or  is  doing  so,  I 
think  he  may  consider  himseK  fortunate  if  he  escape  without  the  ne- 
cessity for  having  a  second  stone  removed  from  the  bladder.     Some 


RECURRENCE  OF  STONE  AFTER  OPERATION.  319 

years  ago  I  cut  a  man  for  stone ;  just  as  he  was  about  to  leave  the 
hospital  he  had  a  most  acute  attack  of  renal  colic,  with  hsematuria, 
and  passed  a  uric  acid  calculus  almost  as  large  as  an  ordinary  marble. 
Had  this  stone  remained  in  the  bladder  it  would  probably  have  grown 
by  the  aggregation  of  phosphates  upon  it.  It  will  be  seen  how  easily 
I  might  at  a  later  date  have  been  exposed  to  the  charge  of  having  left 
a  stone  in  the  bladder  at  the  previous  operation.  Similar  illustra- 
tions of  this  kind  of  recurrence,  quite  independent  of  th'e  selection  of 
the  operation  or  the  manner  of  its  performance,  might  easily  be 
furnished. 

(3)  In  the  last  place  reference  may  be  made  to  the  development  of 
conditions  favorable  to  the  production  of .  stone  which  had  no  exis- 
tence prior  to  the  removal  of  the  original  calculus.  That  such  is 
probable  is  indicated  from  illustrations  of  which  the  following  is  an 
example. 

Case. — A  gentleman  about  60,  of  a  gouty  habit,  consulted  me. 
I  detected  a  moderate-sized  uric  acid  calculus  lying  behind  his  large 
prostate,  which  I  removed  by  crushing.  When  collected  the  frag- 
ments were  entirely  composed  of  urates  with  no  phosphates.  After 
some  months,  his  large  prostate  began  to  trouble  him  for  the  first  time. 
He  found  he  could  not  empty  his  bladder  completely,  and  this  gave 
rise  to  more  or  less  catarrh.  Three  years  after  the  removal  of  the 
uric  acid  calculus  he  came  to  me  again,  when  I  found  he  had  two 
stones  of  moderate  size.  These  I  also  removed  by  crushing.  On 
examination,  unlike  the  previous  calculus,  they  were  entirely  made  of 
triple  phosphates,  and  did  not  contain  one  particle  of  urates  in  their 
composition. 

The  mode  in  which  triple  phosphatic  stone,  as  the  recurring  type 
of  calculus,  is  produced  is  a  subject  of  considerable  interest.  In  a 
paper'"  relating  to  it  Mr.  Cadge  evidently  seems  to  connect  the  fre- 
quency of  stone  recurrence  with  difficulty  of  ensuring  that  every  portion 
of  the  primary  formation  is  removed  from  the  bladder.  On  the  other 
hand,  he  believes  that  structural  lesions,  such  as  those  observed  in 
connection  with  lithotomy,  are  capable  of  providing  a  nucleus  on 
which  phosphates  may  be  deposited,  in  the  same  way  as  upon  a  nu- 
cleus of  stone,  provided  the  state  of  the  urine  admits  of  this.  I  ven- 
ture to  think  that  perhaps  he  somewhat  underestimates  the  frequency 
with  which  lesions  of  this  nature  come  into  play  in  connection  with 
lithotrity.  Where  the  bladder  is  much  pouched,  as  is  the  case  with 
stones  complicated  with  an  enlarged  prostate,  though  the  bulk  of  the 
urine  may  be  acid  the  contents  of  the  sacs  are  often  both  alkaline  and 
ammoniacal,  as  may  be  frequently  noticed  in  cases  where  a  residuum 
of  urine  always  remains.  Further,  as  I  pointed  out  in  my  Hunterian 
Lectures,  we  do  not  attach  sufficient  importance  to  the  influence  that 


320  HAEEISON — ^DISEASES   OF  THE  BLADDER. 

has  been  exercised  on  tlie  bladder  wall  partly  by  the  presence  of  the 
stone  and  partly  by  the  protracted  measures  that  are  sometimes  nec- 
essary for  the  removal  of  the  calculus  by  a  crushing  operation.  A 
rough  or  uneven  cicatrix  or  scar,  as  Mr.  Cadge  mentions  in  his  paper, 
is  not  always  the  best  substitute  for  a  natural  mucous  membrane.  I 
have  often  been  struck  with  the  appearance  presented  by  the  urine  at 
varying  intervals  after  the  stone  has  been  taken  away.  Masses  of 
flocculent  matter  are  thrown  off  sometimes  for  weeks,  which  are  as 
capable  of  furnishing  a  nucleus  for  phosphates  as  a  feather,  a  villous 
growth,  or  a  rugose  bladder.  It  may  be  objected  that  such  argu- 
ments would  apply  with  equal  if  not  greater  force  to  lithotomy,  where 
the  proportion  of  stone  recurrence  is  considerably  less.  On  the  other 
hand,  I  would  reply  that  the  involuntary  urine  drainage  the  latter 
operation  entails  is  as  salutary  to  the  inflamed,  or  excoriated,  or  dis- 
torted bladder  as  the  drainage  of  pus  often  is  to  a  chronic  abscess ; 
and  further,  that  the  selection  of  lithotrity  by  no  means  implies 
that  less  damage  to  the  interior  of  the  bladder  is  necessarily  done  hy 
this  process.  I  have  examined  some  cases  after  death  where  lithot- 
omy had  previously  been  practised,  at  various  periods  of  time,  with- 
out being  able  to  discover  any  internal  trace  of  the  procedure.  Can 
we  say  the  same  of  some  cases  of  lithotrity  where  hemorrhage  has 
been  considerable  both  at  the  time  and  after  the  operation? 

Because  urine  may  be  comparatively  stagnant  or  quiescent  in  a 
saccule  or  pouch  connected  with  a  bladder  which  in  other  respects  is 
healthy,  it  does  not  follow  that  the  conditions  going  on  within  the  sac 
are  the  same  as  when  a  stone  is  removed  from  such  an  organ  by  a 
more  or  less  protracted,  and  not  necessarily  innocuous,  proceeding. 
In  delDating  this  point,  Mr.  Cadge  shows  that  alkaline  and  offensive 
urine  holding  thick  mucus  in  excess  is  not  sufficient  to  lead  to  the 
formation  of  phosphatic  stone,  by  reference  to  the  common  instances 
where  this  constantly  exists  in  connection  with  some  forms  of  pros- 
tatic hypertrophy.  What,  however,  may  I  ask,  would  be  the  effect 
of  adding  to  these  conditions  favorable  to  the  formation  of  a  phos- 
phatic stone,  another  one  in  the  shape  of  constant  contact  with  a 
more  or  less  rough  cicatrix,  not  to  say  anything  of  the  presence  in  the 
urine  of  certain  material  products  of  inflammation  capable  of  being 
demonstrated?  .  It  appears  to  me  that  there  is  sufficient  evidence  to 
indicate  what  is  almost  sure  to  follow. 

Prevention  of  Recurrence. — From  the  foregoing  observations  some 
practical  conclusions  may  be  drawn  under  the  several  headings. 

(1)  In  the  conduct  of  all  operations  for  the  removal  of  stone  from 
the  bladder  every  care  should  be  taken  to  render  the  process  a  com- 
plete one.     The  impossibility  of   doing  so   by  one  method,  either 


EECUREENCE  OP  STONE  AETER  OPERATION.  321 

proved  or  rendered  probable,  would  necessitate  the  selection  of 
another.  The  recurrence  of  stone  after  lithotrity  may  indicate  the 
propriety  of  an  ocular  or  digital  exploration  of  the  bladder  by  some 
method,  such,  for  instance,  as  perineal  lithotrity,  where  the  bladder 
and  its  recesses  may  not  only  be  more  effectually  cleared  of  all  stone 
and  fragments,  but  where  the  viscus  may  be  submitted,  in  addition, 
to  a  process  of  drainage.  The  shape  of  some  bladders,  as  consequent 
on  obstructive,  mechanical,  or  developmental  changes,  is  such  as  to 
render  the  removal  of  all  particles  almost  impossible.  On  the  other 
hand,  where  the  bladder  is  healthy,  or  approximately  so,  the  success 
of  lithotrity  can  now  be  almost  absolutely  guaranteed. 

(2)  As  the  mechanical  removal  of  a  stone  from  the  bladder  does 
not  necessarily  imply  that  the  conditions  which  led  to  its  production 
cease  to  exist  with  the  completion  of  the  operation,  states  favorable 
to  reproduction — as,  for  instance,  in  the  case  of  diathetic  stones,  such 
as  the  urate,  the  oxalate,  and  even,  it  may  be  presumed,  the  cystine — 
should  be  carefully  watched.  Persons  in  the  habit  of  excreting  large 
amounts  of  uric  acid  in  a  crystalline  form,  or  in  the  shape  of  renal 
calculi,  are  placed  at  a  considerable  disadvantage  when  the  prostate 
commences  to  impede  micturition  and  to  render  certain  parts  of  the 
bladder  dependent.  Under  such  conditions  important  alterations  in 
the  amount  and  form  of  crystalline  excretions  may  be  effected  by 
means  of  diet,  exercise,  and  suitable  waters.  On  manifestations  of 
the  diathesis  continuing  after  the  removal  of  uric  acid  calculi  from 
the  bladder,  I  have  seen  excellent  effects  follow  the  use  of  the  Con- 
trexeville  waters  in  combination  with  other  means  to  which  reference 
has  already  been  made.  In  some  cases  this  seems  to  have  been  at- 
tributable to  changes  in  the  form  of  the  excreted  crystals  thus  arti- 
ficially brought  about. 

(3)  In  the  last  place,  much  may  often  be  done  to  prevent  the  devel- 
opment of  conditions  favorable  to  the  reproduction  of  stone  in  some 
form,  after  its  removal.  This  has  reference  more  particularly  to 
those  changes  in  the  parts  which  are  favorable  to  the  formation  of 
calculi  or  concretions  consisting  more  or  less  of  triple  phosphates. 
The  urine  of  patients,  after  lithotrity  especially,  should  be  watched 
for  some  time,  until,  in  fact,  all  traces,  physical  as  well  as  chemical, 
which  may  be  regarded  as  favoring  such  a  tendency,  have  ceased  to 
exist.  Unless  this  can  be  brought  about,  the  liability  to  recurrence 
must  be  said  to  continue.  Urine  that  still  contains  shreds  and 
particles  of  inflammatory  exudation,  or  which  is  alkaline  or  ammo- 
niacal,  may  be  regarded  as  containing  factors  necessary  for  the  for- 
mation of  triple-phosphatic  stones.  When  such  conditions  are  con- 
stantly in  existence,  the  completion  of  the  process  of  stone  formation 

VojL.  I.— 21 


322  ECAEEISON — DISEASES  OF  THE  BLADDEB. 

is  often  only  a  matter  of  time  whicli  some  mere  accidental  circum- 
stance, in  furnishing  what  is  required,  may  determine.  By  local  and 
general  means,  such  as  those  mentioned  in  connection  with  the  toilet 
of  the  bladder,  these  conditions  may  be  prevented.  In  addition  to 
these  measures,  benefit  will  often  be  derived,  in  bringing  about  a  more 
natural  condition  of  the  mucous  membrane  of  the  bladder,  as  well  as 
the  urinary  tract  generally,  by  the  sulphur  springs  of  Harrogate  or 
Strathpeffer  in  Great  Britain,  or  the  ferruginous  waters  of  Wildun- 
gen  in  Germany.  Bethesda  and  Poland  Spring  waters  are  much 
used  in  the  United  States  and  I  have  reason  to  believe  with  advan- 
tage, after  stone  operations,  particularly  where  there  is  any  doubt  as 
to  the  character  of  the  drinking- Avater.  I  have  not,  however,  sufficient 
knowledge  of  the  springs  on  the  continent  of  America  to  enable  me 
to  speak  of  them  in  detail. 

Reference  has  been  incidentally  made  to  a  paper  by  Sir  William 
Roberts  where  it  is  proposed  to  make  the  lactic  fermentation  predom- 
inate over  the  ammoniacal,  with  the  view  of  preventing  the  deposi- 
tion of  triple-phosphate  concretions.  In  sorae  cases  immediate  and 
permanent  benefit  appears  to  have  resulted,  though  further  observa- 
tion wiU  be  necessary  for  the  purpose  of  establishing  the  value  of  the 
suggestion  from  a  practical  point  of  view.  I  have  endeavored,  in 
the  few  instances  where  the  treatment  has  been  tried,  to  bring  this 
about  by  first  washing  out  the  bladder  with  tepid  water  containing 
from  five  to  ten  grains  of  citric  acid  to  the  pint,  and  then,  after  the 
bladder  has  been  cleansed  in  this  way,  leaving  within  it  a  drachm 
of  extract  of  malt  (bynin)  in  an  ounce  or  so  of  water.  Of  the  value  of 
this  treatment  I  have  ah^eady  had  some  proof. 

Bibliographical  References. 

1.  Lancet,  Sept.  27,  1873. 

2.  Transactions  of  the  Royal  Medical  and  Chinirgical  Society,  Feb.  23,  1887. 

3.  New  York  Medical  Record,  Jan.  23,  1887. 

4.  Lancet,  Dec.  11,  1886. 

5.  Transactions  of  the  Royal  Medical  and  Chirurgical  Society,  Feb.  33,  1887. 

6.  Medical  Times  and  Gazette,  Sept.  38,  1872. 

7.  New  York  Medical  Record,  March  29,  1884. 

8.  Medical  Times  and  Gazette,  June  14,  1879. 

9.  Transactions  of  the  Academy  of  Medicine,  Ireland,  1883. 

10.  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  U.  S.  A. 

11.  Lancet,  Oct.  29,  1887. 

12.  British  Medical  Journal,  Feb.  19,  1887. 

13.  British  Medical  Journal,    July  30,    1887. 

14.  Bristol  Medico-Chirurgical  Journal,  March,  1886. 

15.  Traite  des  Corps  Etrangers  en  Chirurgie,  Paris,  1879. 

16.  Lancet,  Feb.  14,  1885. 


BIBLIOGEAPHICAL  REFERENCES.  323 

17.  British  Medical  Journal  (Epitome) ,  May  14,  1893. 

18.  Transactions  of  the  Medico- Chirurgical  Society  of  Edinburgh,  Dec.  7,  1892. 

19.  British  Medical  Journal,  June  30,  1888. 

20.  Australasian  Medical  Gazette,  July,  1888. 

21.  Medical  Times  and  Gazette,  July  30,  1859. 

22.  London  Medical  Gazette,  October,  1845. 

23.  Liverpool  Medico- Chirurgical  Journal,  January,  1884. 

24.  Diseases  of  the  Nervous  System,  by  Dr.  J.  M.  Charcot,  New  Sydenham 
Society,  1877. 

25.  Dublin  Journal  of  the  Medical  Sciences,  June,  1888. 

26.  New  York  Medical  Record,  Nov.  28,  1891. 

27.  Cambridge  Medical  Society,  Lancet,  Feb.  21,  1885. 

28.  British  Medical  Journal,  July  11,  1874. 

29.  Lancet,  vol.  ii.,  1875,  and  vol.  i.,  1876. 

30.  American  Journal  of  the  Medical  Sciences,  February,  1891. 
81.  Virchow's  Archiv,  vol.  cxviii. ,  1889. 

32.  Lancet,  Oct.  18,  1884. 

33.  New  York  Medical  Journal,  Nov.  1,  1890. 

34.  Lancet,  Feb.  23,  1^78. 

35.  American  Journal  of  the  Medical  Sciences,  April,  1879. 

36.  Lancet,  Feb.  25,  1898. 

37.  Transactions  of  the  Medical  and  Chirurgical  Faculty  of  Maryland,  1878. 

38.  Van  Buren  and  Keyes,  Diseases  of  the  Genito-TJrinary  Organs. 

39.  Royal  Medico -Chirurgical  Transactions,  vol.  lii. 

40.  Annals  of  Surgery,  September,  1892. 

41.  Medico-Chirurgical  Transactions,  vol.  Ixxi. 

42.  Centralblatt  flir  Chirurgie,  No.  49,  December,  1885. 

43.  American  Journal  of  the  Medical  Sciences,  July,  1885. 

44.  Annals  of  Surgery,  April,  1892. 

45.  Proceedings  of  the  Royal  Medico-Chirurgical  Society,  April  24,  1894. 

46.  Transactions  of  the  Provincial  Medical  and  Surgical  Association,  New  Series, 
vol.  ii. 

47.  British  Medical  Journal,  July  29,  1893. 

48.  Guthrie,  Diseases  of  the  Urinary  and  Sexual  Organs,  1836. 

49.  Lancet,  April  18,  1891. 

50.  On  the  Comparative  Infrequency  of  Urinary  Calculi  among  Seafaring 
People,  by  Dr.  A.  Coupland  Hutchison,  F.R.S.,  Royal  Medico-Chirurgical  Trans- 
actions, vols.  ix. ,  xvi.,  xxi. 

51.  British  Medical  Journal,  January  4,  1884. 

52.  Archiv  fiir  klinische  Chirurgie,  xviii. 

53.  Ibid. ,  xix. 

54.  Pathological  Society  Transactions,  vol.  xxxiv. ,  p.  152. 

55.  Ibid.,  vol.  xxxxvi.,  pp.  284,  287. 

56.  "Die  krankhaften  Geschwillste,  "  Bd.  iii. ,  Berlin,  1865. 

57.  Pathological  Histology,  English  translation,  vol.  i. ,  p.  454,  edit.  1872. 

58.  Kaltenbach,    Langenbeck's  Archiv,  xxx.,  1884. 

59.  British  Medical  Journal,  May  21,  1887. 

60.  Gazette  Medicale  de  Paris,  1836.  Transactions  of  the  Societe  Anatomique, 
1861,  p.  191. 

61.  Virchow's  Archiv,  vol.  Ixxxvi. 

62.  Fenwick,  Pathological  Society  Transactions,  xxxvii. 


324  HAERISON — DISEASES  OF  THE  BLADDER. 

63.  Langenbeck's  Archiv,  xvii.,  1874. 

64.  Pathological  Society  Transactions,  xxx^i. ,  p.  283. 

65.  Lancet,  vol.  i.,  1883,  p.  1032. 

66.  Transactions  of  the  Medical  and  Chirtirgical  Society,  March  14,  1893. 

67.  Pathological  Society  Transactions,  xxxvii.,  p.  288. 

68.  Lancet,  April  14,  1891. 

69.  The  Electric  Illumination  of  the  Bladder  and  Urethra,  Churchill,  2d 
edition,  1889  ;  Atlas  of  Electric  Cystoscopy,  by  Burckhardt  and  Fenwick,  Churchill, 
1893.    Supra-Pubic  Electric  Cystoscopy,  Medical  Society  of  London,  April  16,  1894. 

70.  British  Medical  Journal,  May  21,  1887. 

71.  Literature  of  Bilharzia  Haematobia :  Bilharz,  Zeitschrift  fiir  wissenschaft- 
liche  Zoologie,  1851 ;  Griesinger,  Archiv  der  Heilkunde,  1854 ;  Cobbold,  T.  S. , 
Parasites  of  Man  and  Animals,  1879,  p.  38;  Mackie,  British  Medical  Journal, 
Oct.  7,  1882;  Harley,  J.,  Medico -Chirurgical  Transactions,  vols,  xlvii.,  lii.,  liv.  ; 
Sonsino,  P.,  Archives  Generales  de  Medecine,  June,  1876,  p.  650;  Zancarol, 
Transactions  Pathological  Society,  London,  vol.  xxxiii.  ;  Wortabet,  J. ,  Edinburgh 
Medical  Journal,  1879-80;  Roberts,  SirW.,  Urinary  Diseases,  4th  edition. 

72.  Transactions  of  the  Pathological  Society  of  London,  1887. 

73.  Provincial  Medical  Journal,  July  2,  1888. 

74.  Transactions  of  the  Provincial  Medical  and  Surgical  Association,  vol.  x. 

75.  Transactions  of  the  Medical  Society  of  London,  vol.  xiv. 

76.  La  France  Medicale,  vol.  i.,  1883. 

77.  Liverpool  Reports,  vol.  iii. ,  1869.  Liverpool  and  Manchester  Reports,  vol. 
iii.,  1875. 

78.  Transactions  of  the  Royal  Medical  and  Chirurgical  Society,  1858-59. 

79.  Lancet,  Feb.  5,  1876. 

80.  Deutsche  medicinische  Wochenschrift,  June  8,  1892. 

81.  Transactions  of  the  Medical  Society  of  London,  vol.  xiv. 

82.  Transactions  of  the  International  Medical  Congress,  1887. 

83.  Lancet,  April  18,  1891. 

84.  Lancet,  March  14,  1891. 

85.  American  Quarterly  Journal  of  the  Medical  Sciences,  January,  1878. 

86.  British  Medical  Journal,  vol.  ii. ,  1878. 

87.  Boston  Medical  and  Surgical  Journal,  March  23,  1882. 

88.  Indian  Medical  Gazette,  July,  1892. 

89.  Lancet,  Sept.  2,  1888. 

90.  Birmingham  Medical  Review,  May,  1894. 

91.  Lancet,  January  6,  1893. 

92.  Clinical  Surgery,  Sydenham  Society's  Translation,  1881,  p.  273. 

93.  Transactions  of  the  American  Surgical  Association,  1887. 

94.  Liverpool  Medico -Chirurgical  Journal,  July,  1884. 

95.  Litholapaxy  in  Male  Children  and  Adults,  Churchill,  1887. 

96.  Transactions  of  the  Pathological  Society  of  London,  February  1,  1887. 

97.  Lancet,  June  1,  1872. 

98.  Diseases  of  the  Urinary  Organs,  1872,  Wm.  Wood  &  Co.,  New  York. 

99.  De  la  Lithotritie  Perineals,  Paris,  1872. 

100.  Medical  Press,  Oct.  12,  1892. 

101.  Annals  of  Surgery,  April,  1893. 

102.  Edinburgh  Medical  Journal,  July,  1879. 

103.  Boston  Medical  and  Surgical  Journal,  July  20,  1876. 

104.  Obstetrical  Society's  Transactions,  April  7,  1880. 


BIBLIOGRAPHICAL  REFERENCES.  325 

105.  Edinburgh  Medical  Journal,  Oct.  1878. 

106.  Archiv  fiir  klinische  Chirurgie,  volxxv. ,  1883. 

107.  The  Supra-Pubic  Operation  of  Opening  the  Bladder,  Churchill,  1886. 

108.  Dr.  Cruise,  New  York  Medical  Record,  Aug.  1,  1881. 

109.  British  Medical  Journal,  Oct.  19,  1889. 

110.  British  Medical  Journal,  Nov.  19,  1893. 

111.  Lancet,  May  27,  1893. 

112.  Binningham  Medical  Record,  April,  1892. 

113.  British  Medical  Journal,  Feb.  18,  1888. 

114.  Transactions  of  Medico- Chirurgical  Society,  1878. 

115.  Transactions  of  Norwich  Medico- Ciiirurgical  Society,  1870. 


DISEASES  OF  THE  PROSTATE. 


BY 


G.  FRANK  LYDSTON, 


CHICAGO. 


DISEASES  OF  THE  PROSTATE. 


An  exhaustiye  anatomical  description  of  tlie  prostate  would  not 
be  in  keeping  with  the  character  of  this  work,  but  it  is  almost  impos- 
sible to  give  a  practical  outline  of  the  various  diseases  affecting  this 
organ  without  a  preliminary  discussion  of  some  of  the  main  points 
of  its  anatomy  and  physiology.  Especially  is  this  necessary  in 
view  of  the  fact  that  our  text-books  upon  anatomy  are  notably  defec- 
tive in  their  descriptions  of  this  particular  structure.  Slight  atten- 
tion is  usually  given  to  the  prostate  in  the  dissecting-room,  compara- 
tively few  students  acquiring  even  a  superficial  knowledge  of  its 
structure  and  functions.  Without  entering  into  an  elaborate  discus- 
sion of  the  views  of  those  who  believe  the  prostate  to  be  essentially  a 
muscle,  or  of  their  opponents  who  claim  that  it  is  essentially  a  gland, 
it  will  suffice  to  say  that  the  prostate  is  a  musculo-glandular  organ, 
situated  at  the  outlet  of  the  bladder  and  surrounding  the  neck  of  that 
viscus.  It  lies  behind  the  triangular  ligament  or  deep  perineal  fascia 
and  impinges  upon  the  rectum,  through  the  thin  walls  of  which  it 
may  readily  be  palpated  by  the  finger.  The  relation  of  the  organ 
to  the  rectum  is  one  of  the  most  important  of  its  gross  anatomical  re- 
lations, having  a  very  important  bearing  upon  both  the  symptomatol- 
ogy and  diagnosis  of  prostatic  disease.  The  close  anatomical  associ- 
ation of  the  prostate  and  rectum  very  often  results  in  coincidental 
disturbance  in  both  organs,  through  the  medium  of  the  associated 
nerve  supply,  as  a  consequence  of  disease  in  one  or  the  other. 

In  a  general  way,  the  old  description  of  the  prostate  as  resembling 
a  horse-chestnut  is  quite  accurate,  as  regards  both  shape  and  size. 
The  organ  measures  on  the  average  about  an  inch  and  a  half  in  breadth, 
three-quarters  of  an  inch  antero-posteriorly,  and  somewhat  less  than 
an  inch  in  thickness.  The  prostate  is  supported  by  the  pubo-pro- 
static  ligaments,  derived  from  the  anterior  vesical  ligaments,  the 
posterior  layer  of  the  triangular  ligament,  and  the  levator  ani  muscle. 
The  organ  presents  the  appearance  of  two  moderately  distinct 
lateral  halves  or  lobes.  The  so-called  median  lobe  is  a  misnomer, 
this  structure  being  a  pathological  formation.  It  is  not  sur- 
prising that  such  a  mistake  should  be  quite  general  when  authorities 


330  LYDSTON — DISEASES  OP    THE    PROSTATE. 

state,  as  does  one  excellent  anatomist,  that  the  median  lobe  is  a 
cause  of  obstruction  in  fully  twenty  per  cent  of  prostates  after  the 
age  of  sixty.  The  prostate  is  tunnelled  by  the  urethra  and  by  the 
prostatic  and  ejaculatory  ducts.  On  its  floor  is  a  longitudinal,  highly 
sensitive,  erectile  structure,  known  as  the  veru  montanum.  This  is 
supposed  to  be  the  principal  seat  of  sexual  sensibility.  Upon  either 
side  of  the  veru  montanum  is  a  longitudinal  depression,  the  prostatic 
sinus,  into  which  open  the  prostatic  ducts,  some  fifteen  or  twenty 
in  number.  At  the  anterior  extremity  of  the  veru  montanum  are 
situated  the  mouths  of  the  ejaculatory  ducts  one  upon  each  side. 
Just  in  front  of  the  veru  montanum  is  a  depression  known  as  the 
uterus  masculinus  or  prostatic  utricle,  from  its  supposed  homology 
to  the  uterus.  The  prostatic  urethra  does  not  traverse  the  prostate 
in  the  same  manner  in  all  individuals,  the  roof  of  the  canal  being 
barely  covered  in  by  prostatic  tissue  in  some  cases.  It  does  not  al- 
ways begin  anteriorly  in  the  centre  of  the  prostatic  apex,  being  occa- 
sionally deflected  to  one  or  the  other  side,  as  shown  by  specimens 
in  the  possession  of  the  author. 

The  length  of  the  prostatic  urethra  and  the  direction  of  its  cun^e 
vary  greatly.  In  the  average  adult  it  measures  about  an  inch  and  a 
quarter  in  length.  Its  curve  is  quite  sharp  and  shoii  in  the  child,  is 
longer  and  more  gradual  in  the  adult.  A  knowledge  of  the  normal 
curve  of  the  prostatic  urethra  is  of  great  importance  in  diagnostic 
explorations  of  the  canal,  inasmuch  as  pathological  conditions  of  the 
organ  or  the  tissues  about  the  vesical  neck  produce  alteration  in  the 
conformation  or  length  of  the  prostatic  urethra.  The  structure  of 
the  prostate  differs  somewhat  in  children  and  adults.  The  assertion 
has  been  made,  and  accepted,  in  certain  quarters  that  children  have 
no  prostate.  This,  however,  is  incorrect.  The  difference  between  the 
child  and  the  adult  is  mainly  in  the  direction  of  the  relative  propor- 
tion of  glandular  and  fibro-muscular  elements.  Even  in  very  young 
children  the  muscular  elements  of  the  prostate  are  sufficiently  abun- 
dant to  give  a  sharply  defined  and  prominent  character  to  the  organ. 
The  glandular  and  fibro-connective-tissue  elements,  however,  are  not 
so  abundant  and  well  marked  as  in  the  adult.  The  veru  montanum, 
ejaculatory  ducts,  and  mouths  of  the  prostatic  follicles  and  the  semi- 
nal vesicles — which  are  so  closely  associated  with  the  prostate  and  its 
functions — are  capable  of  definite  demonstration  even  in  young  in- 
fants. The  argument  has  been  advanced  that  children  really  have 
no  prostate,  because,  its  function  being  purely  sexual,  there  is  no 
occasion  for  its  development  until  such  time  as  the  sexual  power 
manifests  itself.  This  argument  is  not  particularly  logical,  in  view 
of  the  fact  that  the  seminal  vesicles  and  veru  montanum,  which  are 


ANATOMY  AND  PHYSIOLOGY.  331 

perhaps  of  more  importance  from  a  sexual  standpoint  than  the  glan- 
dulo-muscular  elements  of  the  prostate,  are  disproportionately  devel- 
oped in  infants.  A  superficial  dissection  shows  that  in  spite  of  all 
argument  very  young  children  have  well-developed  prostates,  a  spar- 
sity  of  the  prostatic  glandular  tissue  to  the  contrary  notwithstanding. 
In  a  general  way,  however,  it  may  be  asserted  that  the  prostate  is  of 
no  great  functional  importance  until  the  period  of  puberty  arrives. 
Whether  its  muscular  tissue  is  of  importance  in  the  function  of  mic- 
turition, thus  rendering  the  organ  to  a  certain  extent  a  urinary  one, 
is  a  question  which  has  excited  much  controversy.  In  the  author's 
opinion,  while  urination  might  be  carried  on  in  the  absence  of  the 
muscular  tissue  of  the  prostate,  the  organ  nevertheless  appears  to 
have  a  distinct  part  in  the  physiology  of  micturition.  While  admit- 
ting, then,  that  the  prostate  is  to  all  intents  and  purposes  a  procreative 
organ,  it  would  seem  that  it  is  a  participant  in  the  function  of  mic- 
turition and  should,  therefore,  receive  consideration  as  a  urinary  organ 
as  well. 

In  infants  the  muscular  structure  of  the  prostate  is  practically 
continuous  with  the  muscular  structures  of  the  vesical  walls.  As  the 
subject  grows  older  a  certain  amount  of  circumscription  and  rein- 
forcement of  the  prostatic  muscular  tissue  seems  to  occur,  so  that 
there  is  a  more  distinct  line  of  demarcation  between  the  prostatic  and 
vesical  muscular  tissue,  although  the  circular  fibres  of  the  prostate 
are  still  continuous  at  the  outlet  of  the  bladder  with  the  false  sphinc- 
ter of  that  organ. 

On  section  the  prostate  is  of  a  pale  reddish  color,  rather  dense 
and  firm,  and  quite  friable,  the  fibro-muscular  elements  being  con- 
tained in  a  proper  fibrous  capsule.  The  impression  derived  from  the 
usual  descriptions  of  the  prostate  is  that  its  glandular  and  conse- 
quently its  most  important  elements  from  a  functional  standpoint  are 
contained  within  the  proper  fibrous  capsule  of  the  organ.  This,  the 
author  is  convinced,  is  an  error.  The  principal  glandular  elements 
of  the  prostate  are  outside  the  circumscribed  structure  which  we  know 
as  the  prostate  body  proper,  in  the  tissues  surrounding  the  prostate, 
seminal  vesicles,  and  neck  of  the  bladder.  The  glands  and  ducts  are 
numerous  and  form  the  tissue  mass  of  which  the  seminal  vesicles  con- 
stitute the  most  important  part.  This  tissue  is  richly  supplied  with 
nerves  and  blood-vessels.  A  consideration  of  this  particular  feature 
of  the  anatomy  of  the  prostate  serves  to  explain  the  obstinacy  of 
infectious  diseases  involving  this  organ.  It  lays  peculiar  emphasis 
upon  the  oft-repeated  assertion  of  the  intrinsic  incurability  of  gonor- 
rhoeal  infections  of  this  i^art.  A  careful  dissection  of  the  prostate 
and  its  associated  glandular  structures  about  the  neck  of  the  bladder 


LYDSTON — DISEASES  OF  THE  PROSTATE. 

is  very  interesting  to  those  who  believe  that  deep  gonorrhoea!  infections 
in  the  male  are  to  be  speedily  cured  by  instillations  of  a  few  drops 
of  nitrate  of  silver  solution  into  the  prostatic  urethra. 

The  muscular  elements  are  arranged  in  a  circular  fashion  forming 
posteriorly  a  rather  distinct  muscular  ring,  constituting  the  dividing 
line  between  the  vesical  cavity  and  the  true  vesical  neck,  i.e.,  the 
prostatic  urethra.  This  ring  of  circular  fibres  constitutes  the  inter- 
nal or  false  sphincter  vesicae.  Anteriorly  the  muscular  fibres  of  the 
prostate  are  continuous  with  the  accelerator  urinse  muscle  surround- 
ing the  membranous  urethra.  It  would  be  difficult  to  say  whether 
or  not  the  false  sphincter  vesicse  is  a  part  of  the  muscular  structure 
of  the  vesical  wall,  or  of  the  prostate.  The  question  is  of  no  great  mo- 
ment, inasmuch  as  there  is  practically  a  structural  and  functional  con- 
tinuity between  the  prostate  and  bladder  muscle  even  in  the  adult. 
The  tendency  has  been  rather  in  the  direction  of  a  too  arbitrary 
differentiation  between  the  two  organs,  a  differentiation  which  is 
hardly  warrantable  from  a  physiological  standpoint,  except  in  so  far 
as  the  sexual  function  of  the  prostate  is  concerned. 

The  circulatory  supply  of  the  prostate  is  very  abundant.  The 
arteries  are  derived  from  the  internal  pudic,  hemorrhoidal,  and  vesi- 
cal. The  veins  form  an  elaborate  and  intricate  plexus  about  the 
organ,  inosculating  with  those  supplying  the  rectum  and  anus  in  a 
very  intimate  manner.  This  peculiar  relationship  of  the  vascular 
supply  of  the  rectum,  anus,  and  prostate  explains  to  a  certain  de- 
gree the  close  pathological  relationship  of  these  structures.  Thus 
hemorrhoids,  constipation,  and  hepatic  obstruction  are  liable  to  lead 
to  passive  congestion  of  the  prostate,  and  even  predispose  to  ac- 
tive inflammation.  Conversely,  inflammatory  and  congestive  distur- 
bances of  the  prostate  are  apt  to  produce  rectal  tenesmus,  hemor- 
rhoids, or  even  proctitis.  Thompson  has  called  attention  to  the  fact 
that  the  veins  of  the  prostatic  plexus  are  prone  to  become  tortuous 
and  varicose  in  elderly  subjects.  This  condition  of  the  veins  is  often 
associated  with  a  similar  condition  of  the  hemorrhoidal  vessels. 

The  nerve  supply  of  the  prostate  is  derived  mainly  from  the  hypo- 
gastric plexus.  The  organ  is  most  liberally  supplied  with  filaments 
from  the  sympathetic.  This  sympathetic  supply  is  closely  associated 
with  that  of  the  rectum  and  anus,  a  relationship  which  in  some  cases 
forms  another  strong  link  of  pathological  connection  between  the  two 
organs.  By  a  consideration  of  the  nerve  anatomy  of  these  parts  we 
are  able  to  understand  the  strangury,  spasmodic  stricture,  and  reten- 
tion of  urine  which  not  infrequently  occur  as  a  result  of  operations 
about  the  rectum  and  anus.  The  elaborate  sympathetic  nerve  supply 
of  the  prostate,  and  particularly  of  the  prostatic  urethra,  is  explana- 


ANATOMY  AOT)  PHYSIOLOGY.  333 

tory  of  the  more  or  less  remote  reflex  disturbances,  both  mental  and 
physical,  that  so  frequently  occur  as  a  result  of  prostatic  disease.  By 
means  of  the  sympathetic  nerve  supply  the  prostate  is  brought  into 
most  intimate  relations  with  all  the  organs  in  the  function  of  which 
the  sympathetic  ganglia  play  an  important  role. 

The  sexual  function  of  the  prostate  is  rather  a  complex  one,  being 
made  up  of  several  elements,  namely,  special,  sensory,  secretory,  and 
mechanical.  We  will  leave  its  urinary  role  out  of  consideration  for 
the  present  because  the  urine  may  be  physiologically  retained  or  ex- 
pelled independently  of  the  existence  of  the  prostate.  The  prostatic 
urethra,  and  especially  its  floor  in  and  about  the  veru  montanum,  is 
the  seat  of  the  urinary  besoin  and  the  pleasurable  sensation  experienced 
in  the  performance  of  the  sexual  function.  The  prostatic  follicles 
secrete  a  milky  fluid,  slightly  acid  in  reaction,  the  function  of  which 
is  to  dilute  and  increase  the  bulk  of  the  seminal  fluid.  The  muscular 
fibres  of  the  prostate  are  involved  in  the  convulsive,  spasmodic  muscu- 
lar action  which  expels  the  semen  during  ejaculation.  This  is  brought 
about  by  a  distinct  reflex  contraction  excited  by  the  over-distention 
of  the  prostatic  urethra  with  seminal  fluid  at  a  time  when  the  nerves 
of  sexual  sensibility  are  in  a  condition  of  relative  hypersesthesia. 

Standard  authorities  upon  anatomy  assert  that  the  follicular  pros- 
tatic glands  in  some  old  subjects  contain  small  calculi,  composed  of 
carbonate  of  calcium  and  animal  matter.  This  assertion  is  based 
upon  the  fact  that  it  is  practically  only  in  old  subjects  that  these 
calculi  are  of  sufficient  size  or  so  located  as  to  give  rise  to  mechanical 
disturbance.  The  author  has  become  convinced  from  the  dissection 
of  a  large  number  of  prostates  in  subjects  under  middle  age,  that 
prostatic  calculi  are  frequently  found  in  young  subjects.  If  the  ex- 
amination of  the  prostate  be  restricted  to  the  tissue  immediately  sur- 
rounding the  prostatic  urethra,  these  calculi  will  not  frequently  be 
found.  If,  however,  the  glandular  tissue  outside  of  the  capsule 
proper — i.e.,  the  glandular  tissue  surrounding  the  base  of  the  pros- 
tate and  neck  of  the  bladder — be  carefully  examined  these  calculi  will 
often  be  met  with.  The  author  has  found  them  in  the  tissues  sur- 
rounding the  neck  of  the  bladder  an  inch  and  a  half  or  more  above 
the  base  of  the  prostate  proper. 

Attention  has  frequently  been  called  to  certain  striking  points  of 
similarity  between  the  prostate  and  uterus,  from  both  an  anatomical 
and  a  physiological  standpoint.  It  is  unnecessary  to  go  into  an  ex- 
haustive discussion  of  this  subject.  It  is,  however,  well  to  remem- 
ber the  existence  of  a  general  resemblance  between  the  two  in  the 
clinical  study  of  diseases  of  the  prostate.  This  is  especially  true 
with  reference  to  the  consideration  of  surgical  measures  of  relief  of 


334  LYDSTON — DISEASES  OF  THE  PEOSTATE. 

circumscribed  neoplasms,  and  to  the  medical  treatment  of  congestive 
and  inflammatory  affections  of  tliis  organ.  Tlie  prostate  is  of  neces- 
sity a  more  obscure  field  for  research  than  tlie  uterus,  hence  analogi- 
cal reasoning  is  sometimes  of  great  clinical  and  therapeutical  value. 

Anomalies  of  Development. 

Congenital  anomalies  of  the  prostate  are  rare,  at  least  from  a  clini- 
cal standpoint.  It  is  probable  that  they  are  more  frequent  than  is 
generally  supposed,  but  from  the  fact  that  they  are  not  likely  per  se 
to  prove  of  pathological  importance,  they  are  not  often  brought  to 
our  attention.  Defective  development  incidental  to  extreme  degrees 
of  hypospadias  and  epispadias  are  occasionally  seen.  In  these  ex- 
treme cases  the  prostate  is  usually  distinguished  by  its  absence.  The 
anomaly  requires  no  consideration  excepting  such  as  is  incidental  to 
the  deformity  of  which  it  is  a  part.  Defective  development  of  the 
prostate  is  quite  frequent  and  is  associated  as  a  rule  with  defective 
development  of  the  sexual  apparatus  as  a  whole.  The  prostate  is 
apt  to  be  wanting  in  cryptorchids.  In  certain  cases  of  sexual  per- 
verts, and  in  individuals  who  are  imperfectly  developed  and  imper- 
fectly differentiated  from  a  sexual  standpoint,  the  prostate  remains 
undeveloped,  this  lack  of  development  being  both  muscular  and 
glandular,  as  might  be  expected  from  the  rudimentary  condition  of 
the  other  portions  of  the  sexual  apparatus.  The  inhibition  of  pros- 
tatic growth  is  due  not  to  a  failure  of  the  individual  to  perform  his 
sexual  functions  in  a  normal  manner,  but  to  an  inhibition  of  develop- 
ment which  may  be  more  or  less  general,  and  which  always  involves 
all  the  component  parts  of  the  sexual  apparatus. 

That  imperfect  or  exaggerated  development  of  the  prostate  occurs 
alone  is  possible,  but  this  is  a  question  which  for  obvious  reasons 
is  extremely  difficult  of  solution.  It  would  seem  that  aberrations  of 
development  of  a  functionally  very  important  structure  of  the  pros- 
.tate,  viz.,  the  vera  montanum,  are  possible.  Independently  of  the 
existence  of  infectious  or  inflammatory  disease,  cases  of  imperfect  or 
exaggerated  development  of  this  structure  probably  occur.  It  would 
be  difficult,  however,  to  eliminate  in  such  cases  the  effects  of  mastur- 
bation and  sexual  excess.  Stricture  of  the  prostatic  urethra  is  as- 
serted by  so  excellent  an  authority  as  Thompson  to  be  an  unknown 
condition.  The  author  has  several  specimens  in  which  distinct 
bridles  of  an  apparently  congenital  character  are  seen  to  be  present 
in  the  anterior  portion  of  the  prostatic  urethra.  Some  other  speci- 
mens in  his  possession  show  an  abnormal  narrowing  of  the  prostatic 
urethra  at  its  junction  with  the  pars  membranosa  and  a  distinct  lateral 


INJURIES  OF  THE  PROSTATE.  335 

deviation  of  the  canal.  In  several  specimens  tlie  prostatic  urethra, 
instead  of  tunnelling  the  centre  of  the  apex  of  the  prostate,  diverges  to 
such  a  distance  from  the  median  line  that  obstruction  to  the  passage 
of  instruments  must  almost  of  necessity  have  been  experienced  during 
the  life  of  the  patient,  had  such  instrumentation  become  necessary. 
It  will  be  readily  understood  that  these  conditions  of  abnormal  nar- 
rowing and  de-viation  in  all  probability  produced  no  disturbance, 
inasmuch  as  there  were  no  evidences  of  disease  of  the  mucous  mem- 
brane to  be  found.  Should  such  a  canal,  however,  become  infected 
with  gonorrhoea,  a  far  different  state  of  affairs  would  be  instituted 
and  considerable  trouble  might  result  from  the  congenital  conditions 
present.  The  author  is  incKned  to  believe  that  such  congenital  de- 
formities of  the  prostatic  urethra  may  be  responsible  for  the  difficulty 
experienced  in  instrumentation  in  some  cases  of  urethral  disease. 

Injuries  of  the  Prostate. 

Traumatism  of  the  prostate,  aside  from  that  incidental  to  surgical 
operations  and  manipulations,  is  exceptional.  Contusions  and  lacer- 
ation of  the  prostate  due  to  direct  force  from  falls  or  blows  are  espe- 
cially rare  on  account  of  the  situation  of  the  organ,  protected  as  it  is 
by  the  pubic  and  ischiatic  rami  and  the  ischial  tuberosities.  The 
force  of  falls  and  blows  upon  the  buttocks  is  usually  broken  by  the 
prominent  osseous  parts.  Blows  upon  the  perineum  are  not  likely  to 
injiu'e  the  prostate  on  account  of  the  distance  of  the  organ  and  the 
elasticity  of  the  musculo-cellular  cushion  constituted  by  the  tissues  of 
the  ano-perineal  region  and  ischio-rectal  fossa.  Accidents  have  been 
known  where  the  membraneous  ui'ethra  has  been  torn  completely 
across  at  the  apex  of  the  prostate,  and  yet  that  organ  has  escaped 
injury.  This  was  long  ago  noted  by  Chopart.  A  crushing  injury 
invohdng  the  prostate  is  almost  necessarily  fatal,  excepting  where  the 
prostate  is  injured  indirectly  through  the  medium  of  fracture  of  the 
pelvic  bones  fragments  of  which  wound  the  organ.  In  cases  of  exten- 
sive crushing  injury  the  traumatism  of  the  prostate  is  comparatively 
a  minor  consideration.  Incised,  punctured,  and  lacerated  wounds  of 
the  prostate  from  accidental  injury  are  occasionally  seen.  Sharp 
bodies  may  be  driven  into  the  perineum,  the  patient  perhaps  falling 
astride  them.  Most  of  the  accidental  injuries  are  due  to  a  fall  upon 
some  pointed  object.  Dugas  cites  a  case  in  which  the  branch  of  a 
tree  was  driven  into  the  perineum  and  the  prostate  wounded  (Forge, 
"Traite  de  Chirurgie").  Velpeau  reports  a  similar  case  in  which  a 
wooden  stake  was  driven  into  the  perineum.  Brittle  substances  in- 
troduced into  the  rectum  have  been  known  to  penetrate  the  prostate. 


336  LYDSTON — DISEASES  OP  THE  PKOSTATE. 

Obviously  such,  penetration  miglit  occur  with  great  facility.  Injury 
to  the  prostate  by  firearms  is  necessarily  very  rare.  Kicord,  however, 
reported  a  case  in  which  a  musket-ball  penetrated  the  false  pelvis, 
passed  downward  along  the  iliac  fossa,  entered  the  true  pelvis,  and 
penetrated  the  prostate.  It  was  detected  by  a  digital  examination 
through  the  rectum  ajid  extracted  by  perineal  section.  Wounds  of 
the  prostate  inflicted  in  the  performance  of  surgical  operations  of 
various  kinds  are  frequent.  It  is  necessarily  wounded  in  all  of  the 
perineal  operations  of  lithotomy  with  the  exception  of  the  simple 
median  or  Marian  operation.  It  is  often  wounded  in  perineal  ure- 
throtomy, and  is  invariably  wounded  in  the  proper  performance 
of  perineal  puncture  for  drainage  of  the  bladder.  Operative  wounds 
of  the  prostate  are  not  dangerous  per  se,  unless  the  incision  or  lace- 
ration, as  in  the  case  of  extraction  of  too  large  a  stone,  extends  beyond 
the  bounds  of  the  fascial  investments  of  the  prostate,  thus  involving 
the  pehdc  cellular  tissue  or  peritoneum.  The  prostate  is  often  in- 
jured from  its  urethral  aspect  in  the  passage  of  the  catheter  or  sound, 
or  in  the  performance  of  that  extremelj^  hazardous  operation,  inter- 
nal prostatotomy.  These  forms  of  prostatic  trauma  are  exceedingly 
dangerous  because  of  the  exposure  of  the  injured  tissue  to  sepsis 
and  the  necessarily  imperfect  drainage.  An  additional  element  of 
danger  is  uncontrollable  hemorrhage.  These  factors  are  done  away 
with  in  perineal  or  suprapubic  operative  wounds  of  the  prostate. 
Another  danger  is  the  formation  of  a  false  urinary  passage.  False 
passages  traversing  the  prostate  and  beginning  in  the  prostatic 
urethra,  or  at  some  point  in  the  urethral  walls  at  a  greater  or  less 
distance  anterior  to  the  ajjex  of  the  organ,  are  very  frequently  seen. 
Instances  have  been  known  in  which  a  catheter  or  sound  has  been 
passed  through  the  urethral  walls  at  some  point  in  front  of  the  bulbo- 
membranous  region  and  made  to  traverse  the  tissues  outside  of  the 
urethra,  penetrating  one  or  the  other  lobe  of  the  prostate,  thus 
reaching  the  bladder  by  a  roundabout  and  most  dangerous  route. 

Besidts  of  Injury. — As  abeady  suggested,  wounds  from  the  inte- 
rior are  most  likely  to  be  followed  by  serious  results,  providing  the 
injury  be  limited  to  the  prostate  itself.  Lacerations  and  contusions 
are  more  dangerous  than  smooth  incisions,  excepting  in  respect  to 
the  danger  of  hemorrhage,  which  is  obviously  greater  in  clean  in- 
cised wounds,  unless  such  wounds  be  external  and  open. 

In  considering  the  question  of  hemorrhage  from  operative  or  ac- 
cidental wounds  about  the  prostate,  it  is  well  to  remember  that  the 
region  of  the  prostate  is  very  vascular  and  rather  difficult  of  access 
for  the  application  of  methods  of  hsemostasis.  Retention  of  urine 
from  congestive  or  inflammatory  occlusion  of  the  urethra,  or  from 


INJUEIES  OF  THE  PROSTATE.  337 

complete,  or  partial  obliteration  of  tlie  canal  as  a  result  of  the  trau- 
matism, is  likely  to  be  the  next  point  for  consideration  in  prostatic 
injuries.  Pyogenic  infection  and  abscess,  possibly  followed  by  uri- 
nary fistula,  and  septic  cellulitis,  are  serious  results  whicli  are  likely 
to  occur  in  extensive  injuries,  especially  those  in  which  drainage  is 
imperfect.  The  septic  cellulitis  may  be  limited  to  the  ano-jjerineal 
region  and  ischio-rectal  fossa,  or  may  extend  over  a  large  area  of  the 
subcutaneous  and  intermuscular  planes  of  cellular  tissue.  In  case 
the  wound  extends  beyond  the  bounds  of  the  prostate,  septic  pelvic 
cellulitis  or  general  peritonitis  may  supervene,  these  latter  conditions 
being  intrinsically  fatal.  Constitutional  manifestations  of  septic  or 
pathogenic  intoxication  may  supervene.  It  will  be  observed  that,  in 
a  general  way,  the  conditions  produced  by,  and  dangers  of,  prostatic 
injuries  are  essentially  the  same  as  in  traumatism  of  the  urethra  and 
bladder. 

Symptoms. — There  is  nothing  characteristic  in  the  symptomatol- 
ogy of  wounds  of  the  prostate.  In  a  general  way,  they  are  similar  to 
those  of  deep  urethral  traumatisms.  The  principal  symptom  pro- 
duced by  the  injury  is  urethrorrhagia,  providing  the  wound  of  the 
prostate  communicates  with  the  urethra.  If  an  open  wound  of  the 
prostate  exists  and  the  urethra  be  injured,  the  hemorrhage  occurs  at 
the  site  of  the  injury  and  also  in  the  form  of  a  urethral  hemorrhage. 
Retention  of  urine  has  already  been  alluded  to,  and  is  an  important 
factor  in  the  symptomatology  of  prostatic  traumatism.  If  the  ex- 
travasation of  blood  into  the  surrounding  tissues  be  extensive,  hsema- 
toma  may  result,  which  may  be  felt  by  way  of  the  rectum,  around 
which  viscus  it  may  burrow  for  a  considerable  distance.  The  local 
and  constitutional  symptoms  which  speedily  follow  serious  injuries 
of  the  prostate  are  by  no  means  distinctive,  but  are  precisely  similar 
to  those  which  follow  urethral  injuries  producing  urinary  infiltration, 
cellulitis,  or  abscess. 

Treatment. — Operative  wounds  from  the  exterior  require  no  spe- 
cial consideration.  In  both  internal  and  external  wounds  which  are 
not  extensive,  and  in  which  a  catheter  can  readily  be  passed,  a  full- 
sized  soft  instrument  should  be  introduced  into  the  bladder  and  re- 
tained from  three  days  to  a  week  or  more  according  to  the  progress 
of  the  case.  Great  care  is  necessary  to  maintain  urethral  asepsis. 
If  the  hemorrhage  be  excessive  and  urinary  extravasation  exist,  or 
if  there  be  any  reason  to  believe  that  the  wound  of  the  prostate  is  of 
a  serious  character,  or  in  any  case  in  which  the  catheter  does  not 
pass  readily,  a  free  perineal  section  should  be  made  and  the  bladder 
drained  by  a  large  tube,  the  after-care  of  the  case  being  based  upon 

strict  principles  of  antisepsis.     In  cases  in  which  the  perineum  is  ex- 
VoL.  1.— 22 


338  LYDSTON — DISEASES  OF  THE  PROSTATE. 

tensively  disorganized  by  the  injury  and  it  is  a  difficult  matter  to  find 
the  proximal  end  of  the  urethra,  suprapubic  cystotomy,  retrograde 
exploration,  and  perineal  incision  should  be  combined.  Through 
and  through  drainage  should  be  instituted  in  such  cases.  In  the 
author's  opinion  this  procedure  is  far  safer  than  a  prolonged  and 
necessarily  haphazard  search  for  the  normal  channel  via  the  peri- 
neum. Infiltration  of  urine  demands  free  incisions  in  any  and  all 
situations  in  which  intumescence  of  the  tissues  is  suggestive  of  the 
presence  of  extravasated  fluid.  The  incisions  can  hardly  be  too  free 
or  too  numerous — with  due  respect  to  anatomical  dangers.  The  same 
principles  should  be  adopted  in  the  management  of  urinary  abscess 
and  cellulitis.  The  early  and  free  use  of  the  knife  in  septic  cases  is 
the  only  hope  of  saving  the  Hfe  of  the  patient.  The  tendency  to 
asthenia,  incidental  to  the  profoundly  depressing  influence  upon  the 
sympathetic  nervous  system  produced  by  injuries  of  this  region,  and 
the  great  danger  of  toxaemia,  constitute  a  direct  and  positive  indica- 
tion for  free  and  liberal  supportive  measures  of  a  dietetic  and  stimu- 
lating character. 

Neuroses  of  the  Prostate   and   Reflex  Neuroses  of  Pros- 
tatic Origin. 

"When  we  consider  the  abundant  nervous  supply  of  the  prostate 
and  its  environs,  and  especially  its  liberal  endowment  Avith  sympa- 
thetic nerve  filaments,  with  its  resulting  intimate  association  with  the 
rectum,  bladder,  and  other  viscera,  it  is  by  no  means  surprising  that 
nervous  phenomena  of  various  kinds,  referable  directly  or  indirectly 
to  disturbance  of  the  prostate,  should  occur.  It  is  true  that  many 
neurotic  disturbances  which  the  author  believes  should  come  prop- 
erly under  the  head  of  neuroses  of  the  prostate  have  their  origin  pri- 
marily in  demonstrable  organic  disease.  The  clinical  fact,  however, 
remains,  that  pronounced  nervous  disturbance,  such  as  direct  or 
reflex  pain,  and  in  some  instances  considerable  psychical  disturbance 
may  persist  and  constitute  the  principal  source  of  disquiet  long  after 
the  primary  organic  cause  has  completely  or  in  great  measure  sub- 
sided. In  either  case  the  primary  condition  is  of  so  httle  moment 
that  there  would  be  little  or  nothing  to  attract  the  attention  of  the 
physician  were  it  not  for  the  disproportionate  nervous  disturbance 
which  results. 

In  using  the  term  neurosis,  the  author  is  weU  aware  that  a  certain 
element  of  ambiguity  must  necessarily  enter  into  the  consideration 
of  the  subject,  but  in  the  present  state  of  our  knowledge  of  disease, 
in  the  light  of  practical  clinical  experience,  and  more  especially  to 


NEUEOSES  AND  REFLEX  NEUROSES.  339 

subserve  the  purposes  of  an  intelligent  therapy,  it  would  seem  that 
the  term  neurosis  is  sufficiently  clear  and  comprehensive. 

In  considering  neuroses  of  the  prostate,  there  are  four  points  to 
be  borne  in  mind :  First,  the  physiological  and  anatomical  analogy 
between  the  prostate  taken  as  a  whole  and  the  uterus.  Second,  the 
relation  of  the  prostate  to  the  function  of  urination.  Tfdrd,  the  sex- 
ual function  of  the  prostate.  Fourth,  the  intimate  association  of  the 
prostate  with  the  rectum,  anus,  seminal  vesicles,  urethra,  and  bladder. 

Neuralgia  and  Hypercesthesia. — Neuralgia  of  prostatic  origin,  un- 
attended with  evidences  of  organic  disease  or  associated  with  very 
slight  organic  changes,  is  by  no  means  rare.  It  is  probable  that  a 
certain  degree  of  hypersemia  exists  in  by  far  the  majority  of  cases 
of  prostatic  neuralgia,  yet  a  disturbance  of  the  circulation  does  not 
seem  to  be  absolutely  necessary  in  such  cases.  Hypersesthesia  of 
the  prostate  is  usually  limited  to  its  urethral  portion  and  is  very 
frequently  met  with.  Hypersesthesia  and  neuralgia  are  often  asso- 
ciated, the  former  being  the  more  likely  to  exist  alone. 

The  causes  of  neuralgia  and  hypersesthesia  of  the  prostate  are : 
(1)  Sexual  excesses  and  masturbation.  (2)  A  gouty  or  rheumatic 
diathesis;  this  constitutes  a  very  potent  predisposing  factor. 
(3)  Traumatism  of  the  prostate,  surgical  and  accidental.  (4)  Acute 
or  chronic  congestion  from  various  causes.  (5)  Acute  or  chronic  in- 
flammation of  infectious  origin.  (6)  Urethral  disease,  notably  stric- 
ture. (7)  Foreign  bodies  or  tumors  in  the  bladder.  (8)  Psychical 
disturbance  with  an  attendant  element  of  mental  suggestion  inciden- 
tal to,  {a)  ignorance  of  sexual  physiology  and  the  influence  of  quack 
literature;  (b)  injudicious  and  perhaps  imnecessary  treatment  of  the 
sexual  organ  under  suspicion ;  or,  (c)  the  prolonged  duration  of  mental 
disturbance  produced  by  actual  organic  disease.  These  cases  are 
especially  liable  to  be  associated  with  hypersemia.  Prostatic  catarrh 
is  also  a  frequent  concomitant. 

It  would  be  difficult  to  disassociate  the  local  irritation  produced 
by  highly  acid  urine  in  gouty  and  rheumatic  patients  from  the  exag- 
gerated nervous  sensibility  produced  by  the  constitutional  effects  of 
lithsemia.  Many  cases  are  found,  however,  in  which  neuralgic  pain, 
referable  to  the  perineum,  anus,  neck  of  the  bladder  and  urethra,  is 
experienced  by  lithsemic  patients  in  whom  the  correction  of  the  acid 
and  irritating  properties  of  the  urine  is  not  followed  by  appreciable 
benefit  until  alkaline  and  anti-lithic  remedies  have  had  sufficient  time 
to  appreciably  modify  the  diathesis  present.  The  author  has  under 
observation  at  the  present  time  the  case  of  a  gentleman  forty-five  years 
of  age,  who  has  been  for  some  years  annoyed  by  neuralgic  pain  of 
the  kind  described,  associated  with  intense  hypersesthesia  of  the  pros- 


340  LYDSTON — DISEASES  OF  THE  PEOSTATE. 

tatic  urethra.  He  is  particularly  annoyed  by  persistent  erections  at 
night,  and  irrespective  of  the  reaction  of  the  urine  the  act  of  urina- 
tion gives  him  considerable  pain.  Careful  examination  of  the  bladder 
and  the  urethra  by  means  of  the  endoscope,  cystoscope,  and  mechani- 
cal exploration  fails  to  reveal  any  organic  condition  which  will  explain 
his  symptoms.  There  is  apparently  no  disturbance  of  the  kidneys 
which  might  by  reflex  irritation  constitute  the  etiological  factor  in 
the  case.  As  far  as  can  be  determined,  the  origin  of  the  difficulty  in 
this  patient  was  a  gouty  constitution  associated  with  strictures  of 
large  calibre.  The  latter  were  operated  upon  by  the  author  some 
years  ago  with  perfect  success  in  every  respect,  save  in  the  failure  to 
ameliorate  what  to  him  appeared  to  be  the  most  annoying  condition. 
Similar  symptoms  are  often  produced  by  rectal  or  anal  irritation,  but 
this  was  not  present  in  this  case.  Pain  of  a  neuralgic  character,  ref- 
erable to  the  perineum  and  neck  of  the  bladder,  and  perhaps  radiat- 
ing into  the  testes,  is  by  no  means  an  unusual  feature  of  disease  of 
the  lower  bowel.     This  is  a  point  worthy  of  remembrance. 

Cases  of  neuralgia  of  the  prostate  following  operations  upon  that 
organ,  or  operations  upon  the  bladder  involving  it,  are  occasionally 
met  with.  The  author  has  at  the  present  time  under  observation  a 
case  in  which  he  operated  through  the  perineum  for  the  purpose  of 
draining  the  bladder  in  a  case  of  obstinate  cystitis  in  a  young  adult. 
The  result  was  perfect  as  far  as  the  cystitis  is  concerned,  but  the  pa- 
tient has  been  tormented  ever  since  the  operation  by  ano-jjerineal 
pain  and  crural  and  testicularneuralgia.  There  is  no  condition  of  the 
prostate,  bladder,  or  rectum  which  will  serve  to  explain  the  difficulty. 
Another  case  is  that  of  a  man  operated  upon  for  large-calibred 
stricture  of  the  penile  urethra,  in  whom  there  have  existed  for  some 
years  a  persistent,  deep-seated,  intermittent  perineal  pain,  frequent 
urination,  and  marked  hypereesthesia  of  the  prostatic  urethra. 
Careful  exploration  failed  to  detect  any  morbid  condition  which 
would  serve  to  explain  the  trouble.  The  operation  of  urethrotomy, 
while  perfectly  effective  as  far  as  the  stricture  was  concerned,  com- 
pletely failed  to  relieve  the  prostatic  neuralgia. 

Acute  or  chronic  hypersemia  of  the  prostate  is  responsible  for 
some  cases  of  hyperEesthesia  and  neuralgia  of  this  organ,  and  in  such 
cases  the  perturbation  of  the  blood  supply  is  really  the  essential  con- 
dition. Unfortunately,  however,  the  pain  is  not  only  the  most 
prominent  feature  in  such  cases  in  the  mind  of  the  patient,  but  it 
often  persists  in  spite  of  all  measures  tending  to  correct  the  circula- 
tory disturbance.  That  a  strong  psychic  element  enters  into  these 
cases,  as  indeed  it  does  in  the  majority  of  cases  of  genito-urinary 
disease,  is  admitted.    Psychical  disturbance,  as  indicated  in  the  etio- 


NEUROSES  AND  REFLEX  NEUROSES.  341 

logical  table  already  given,  may  be  tlie  starting-point  not  only  of  vas- 
cular disturbance  attended  with  neuralgia  and  liypersesthesia,  but 
may  produce  neurotic  disturbance  independently  of  disturbances  of 
the  circulation.  Prolonged  and  unnecessary  treatment  of  the  pros- 
tatic urethra  is  not  only  likely  to  produce  a  hypersesthetic  condition 
of  this  part,  but  also  persistent  and  obstinate  psychical  disturbance, 
perhaps  amounting  to  hypochondriasis  or  even  melancholia,  with 
or  without  painful  sensations,  real  or  imaginary — in  this  region. 
Hysteria  in  the  male  from  this  cause  is  by  no  means  as  infrequent 
as  is  ordinarily  supposed. 

Psychoses  from  prostatic  irritation  are  very  frequent,  but  care 
must  be  taken  to  carefully  discriminate  between  those  cases  which  are 
psychical  ah  initio  and  those  in  which  the  psychical  element  is  simply 
an  ingraft  upon  the  symptoms  produced  by  organic  disturbance. 
Acute  or  chronic  inflammation  of  infectious  origin  is  of  course  the 
most  frequent  condition,  but  many  cases  occur  in  which,  after  the  in- 
flammation has  disappeared,  neuralgic  pain  referable  to  the  neck  of  the 
bladder  and  radiating  into  the  perineum,  testes,  thighs,  and  rectum, 
persists  in  spite  of  all  treatment,  often  perhaps  because  of  it.  Ke- 
flex irritation  produced  either  from  the  vesical  or  urethral  side  of  the 
prostate  is  quite  often  seen.  Urethral  and  perineal  pain,  associated 
with  stricture  and  stone  in  the  bladder,  are  familiar  examples.  Stric- 
ture of  the  urethra  occasionally  produces  neuralgia  referable  not  only 
to  the  prostate,  but  apparently  involving  the  entire  bladder.  A  case 
at  present  under  treatment  demonstrates  this  clinical  fact  to  excellent 
advantage.  A  gentleman,  thirty  years  of  age,  suffered  from  pain  in 
the  region  of  the  bladder  associated  with  frequency  of  micturition,  for 
six  or  seven  years.  He  had  been  operated  upon  for  stricture  some  time 
prior  to  the  beginning  of  his  neuralgic  pain,  and  he  was  inclined  to 
attribute  the  disturbance  to  the  urethrotomy.  Examination  revealed 
several  strictured  bands  of  large  calibre  which  had  evidently  escaped 
the  original  operation.  A  second  urethrotomy  was  advised  and  per- 
formed with  perfect  relief  of  the  patient's  symptoms.  A  peculiar 
feature  in  this  case  was  severe  hypogastric  pain  whenever  the  urine 
was  held  for  several  hours.  This  has  completely  disappeared  since 
the  operation. 

The  term  hypersesthesia  of  the  prostate  should  comprehend  those 
cases  of  so-called  vesical  irritability  which  have  been  described  by 
some  authors  as  neuralgia  of  the  vesical  neck.  The  more  important 
and  highly  sensitive  parts  involved  in  the  sexual  and  urinary  func- 
tions are  integral  parts  of  the  prostate.  The  prostatic  urethra  de- 
rives most  of  its  importance  (save  that  incidental  to  its  function  as 
an  outlet  from  the  bladder)  from  certain  anatomical  and  physiological 


342  LTDSTON— DISEASES  OP  THE  PROSTATE. 

peculiarities  of  tlie  prostate  proper.  Tlie  elaborate  and  highly  sensi- 
tive nervous  supply  of  the  prostate  is  the  seat  of  urinary  desire.  The 
nervous  supply  of  the  prostate  is  also  responsible  by  virtue  of  spe- 
cial nervous  filaments — supplied  chiefly  to  the  caput  gallinaginis — for 
the  voluptuous  sensations  incidental  to  the  performance  of  the  sexual 
function.  Hypersesthesia  of  the  prostate  manifests  itself  in  two 
ways.  First,  by  heightened  sensibility  of  the  prostatic  urethra  to 
the  pressure  of  urine  with  resultant  frequent  micturition.  This  is 
associated  perhaps  with  an  inhibition  of  the  function  of  the  false 
vesical  sphincter,  as  a  consequence  of  which  the  urine  enters  the 
highly  sensitive  prostatic  urethra  at  more  frequent  intervals.  The 
capacity  of  the  bladder  itself  is  in  all  probability  diminished  by  reflex 
irritation  of  the  nervous  supply  to  the  vesical  muscle.  A  careful  con- 
sideration of  the  physiology  of  micturition  readily  explains  the  so- 
called  vesical  irritability  resulting  from  prostatic  hypersesthesia. 
The  sexual  function  of  the  prostate  is  likely  to  be  profoundly  dis- 
turbed by  hypersesthesia  of  the  organ,  particularly  if  the  region  of 
the  caput  gallinaginis  be  involved.  Nocturnal  pollutions,  imperfect 
erection,  and  premature  orgasm,  or  perhaps  complete  impotentia 
coeundi  may  result,  these  conditions  being  by  no  means  readily  amen- 
able to  treatment. 

Treatment. 

The  neuroses  of  prostatic  origin  constitute  a  most  emphatic 
indication  for  attention  to  genito-urinary  hygiene.  Careful  regula- 
tion of  diet,  attention  to  the  various  emunctories  of  the  body,  and 
most  careful  supervision  of  the  sexual  habits  of  the  patient  are 
the  keynote  of  treatment.  Remedies  calculated  to  correct  lithaemia 
are  essential  in  appropriate  cases.  Regulation  of  the  diet,  however, 
is  of  prime  importance  in  such  cases.  Tobacco  and  liquor  are  espe- 
cially to  be  interdicted.  Certain  sedative  remedies  are  often  of  great 
value.  The  bromides,  camphor — or  a  combination  in  the  form  of  the 
monobromide  of  camphor — and  gelsemium  are  of  especial  value,  the 
latter  remedy  perhaps  being  the  most  reliable  of  any  at  our  com- 
mand. Ergot  is  often  of  great  service.  Cold  sitz-baths  and  enemata 
often  give  great  relief.  Careful  attention  should  be  paid  to  the  con- 
dition of  the  bowels.  Strong  cathartics  should  be  avoided  and  mild 
laxatives  given.  The  local  measures  of  relief  are  as  numerous  as 
they  are  unsatisfactory.  In  some  cases  in  which  there  is  a  strong 
psychic  element,  a  cold  sound  or  the  psychrophore  is  of  great  value. 
Should  a  certain  degree  of  actual  organic  disease  of  the  prostatic 
urethra  exist,  however,  these  measures  may  produce  more  harm  than 
good.     In  some  cases  the  nervous  make-up  of  the  patient  is  such  that 


HYPEREMIA   OP  THE  PROSTATE.  343 

local  treatment  simply  serves  to  direct  liis  attention  to  the  part  with 
resulting  exaggeration  of  his  symptoms.  In  cases  where  there  is 
actual  disease  of  the  mucous  membrane  of  the  prostatic  urethra,  the 
judicious  application  of  nitrate  of  silver  by  means  of  the  deep  ure- 
thral syringe  or  the  endoscope  is  of  value.  The  author,  however, 
takes  this  opportunity  of  stating  that '  deep  urethral  injections  have 
probably  been  productive  of  more  damage  in  this  class  of  cases  than 
in  any  other  which  could  be  mentioned.  Many  cases  of  neuralgia 
and  hypersesthesia  of  the  prostate,  in  which  there  primarily  existed 
no  pathological  change  whatever  in  the  deep  urethral  mucous  mem- 
brane, are  treated  so  assiduously  by  deep  urethral  injections  that  the 
erroneous  diagnosis  of  actual  disease  of  the  prostatic  urethra  is  made 
good  by  the  development  of  genuine  pathological  conditions  under 
the  irritating  influence  of  the  local  applications.  It  appears  very 
illogical  in  cases  in  which  careful  local  examination  and  conscientious 
urinalysis  fail  to  show  the  existence  of  organic  disease  of  the  genito-' 
urinary  organs,  to  treat  the  prostatic  urethra  by  frequent"  deep  in- 
jections of  nitrate  of  silver  solution  in  the  attempt  to  cure  a  poste- 
rior urethritis,  which  exists  only  in  the  mind  of  the  practitioner  until 
it  has  been  developed  by  the  treatment  itself.  The  readiness  with 
which  the  diagnosis  of  posterior  urethritis — which  happens  to  be  the 
prevailing  fad — may  be  made,  and  the  ease  with  which  one  may  sup- 
ply himself  with  the  necessary  instruments  for  deep  urethral  injec- 
tions, constitute  a  constant  menace  to  many  patients  who  have 
genito-urinary  disease,  real  or  imaginary.  In  cases  in  which  actual 
organic  disease  exists,  the  first  duty  of  the  surgeon  is  to  institute 
appropriate  measures  for  its  removal.  While  it  is  best  from  a 
psychical  standpoint  to  imi^ress  the  patient  with  the  radical  result 
expected  to  accrue  from  the  treatment,  the  surgeon  should  remember 
that  even  after  the  original  organic  difiiculty  has  been  cured  the  neu- 
rosis may  remain.  The  experience  derived  from  the  removal  of  the 
original  cause  in  reflex  neuralgias  in  other  situations  has  been  that 
the  neuralgia  frequently  persists  in  spite  of  a  radical  operation  for 
the  removal  of  the  offending  part.  The  same  argument  applies  to 
neuralgia  and  hypersesthesia  of  the  prostate. 

Hypersemia  of  the  Prostate. 

The  line  of  demarcation  between  prostatic  hypersemia,  active  or 
passive,  and  true  inflammation  is  often  rather  indefinite.  From  a 
pathological,  and  more  esi)ecially  from  a  clinical,  standpoint,  there 
are,  nevertheless,  many  cases  of  prostatic  disease  which  fall  rather 
under  the  head  of  active  or  passive  hyi)er9emia  than  of  actual  inflam- 


344  LYDSTON — DISEASES  OF  THE  PROSTATE. 

mation.  That  conditions  of  hypersemia  predispose  to,  and  are  likely 
to  terminate  in,  true  inflammation,  is  well  understood  even  by  tlie 
tyro  in  medicine.  Especially  is  tMs  true  of  prostatic  diseases  involv- 
ing local  disturbances  of  circulation.  This  proposition  is,  therefore, 
taken  for  granted  as  a  preliminary  to  the  discussion  of  prostatic 
hypergemia.  In  perhaps  the  ma.jority  of  cases  of  acute  prostatic  dis- 
ease which  fall  under  the  observation  of  the  practitioner,  the  diag- 
nosis of  prostatitis,  acute  or  chronic,  is  made  and  allowed  to  pass 
without  question.  That  no  harm  results  therefrom  in  the  majority  of 
cases  is  simply  due  to  the  fact  that  the  principles  of  treatment  are 
essentially  the  same  in  both  conditions.  In  some  cases,  however, 
there  is  little  doubt  that  a  true  appreciation  of  the  conditions  pres- 
ent would  be  of  direct  benefit  to  the  patient,  as  in  certain  cases  of 
passive  congestion  from  venous  obstruction.  Measures  calculated  to 
relieve  passive  hypergemia  are  likely  to  prevent  the  development  of 
true  inflammation. 

Active  prostatic  hypergemia  has  its  point  of  departure,  as  a  rule,  in 
disturbance  either  of  the  sexual  function,  or  of  the  physiological  act 
of  micturition.  The  prostate  is,  from  time  to  time,  the  seat  of  physi- 
ological hypergemia,  as  is  true  of  all  glandular  organs.  This  attends 
sexual  excitement,  however  such  excitement  may  be  produced.  Under 
normal  conditions  the  circulation  resumes  its  normal  status  as  soon 
as  the  source  of  excitement  has  been  removed.  The  return  to  its  nor- 
mal circulatory  condition  is  still  more  rapid  when  the  sexual  function 
has  been  performed  in  a  normal  manner.  Prolonged  excitement  with- 
out gratification  is  perhaps  the  most  prolific  source  of  prostatic 
hypergemia.  Frequent  masturbation  and  sexual  excess  will  also  pro- 
duce marked  circulatory  excitement  of  a  more  or  less  permanent 
character.  The  periods  of  rest  between  the  acts  of  ejaculation  are  so 
short  that  the  circulation  has  no  time  to  regain  its  normal  equilibrium. 
Sexual  excess  and  masturbation  are  still  more  potent  factors  in  the 
production  of  pathological  hypergemia  when  associated  with  erotic 
mentality,  alcohol  and  other  elements  of  high  living,  or  the  gouty  and 
rheumatic  diathesis.  If  the  causes  of  hypergemia  be  long  continued, 
subacute  or  chronic  inflammation  will  probably  supervene. 

The  relation  of  sexual  excitement  to  the  production  of  morbid  con- 
ditions of  the  prostate  should  receive  the  greatest  consideration.  It 
should  be  understood  that  physical  continence  may  be  associated, 
so  to  speak,  with  mental  incontinence,  with  resulting  prostatic 
hypergemia  which  may  give  rise  to  both  functional  and  organic 
changes  in  the  affected  part.  As  will  be  seen  in  a  subsequent  chap- 
ter, it  is  the  author's  conviction  that  prostatic  hypergemia  from  fre- 
quently repeated  and  prolonged  sexual  excitement  is  an  important 


HYPEREMIA  OF  THE  PROSTATE.  345 

factor  in  the  etiology  of  prostatic  hypertropliy.  Tlie  importance  of 
avoiding  all  sources  of  sexual  excitation,  both  mental  and  physical, 
cannot  be  too  strongly  insisted  upon  in  the  management  of  all  dis- 
eases affecting  the  prostate  and  neck  of  the  bladder. 

A  greater  or  less  degree  of  prostatic  hyperaemia  is  probably  an 
almost  constant  concomitant  of  urethral  and  bladder  disease,  whether 
acute  or  chronic,  and  is  due  in  these  cases  not  only  to  an  inflamma- 
tion of  vesico-urethral  mucous  membrane  per  se,  but  also  to  the 
frequent  acts  of  micturition  necessitated  by  irritation  of  the  vesical 
neck.  The  termination  of  the  act  of  micturition  is  characterized  by 
reflex  spasm  of  the  cut-oif  muscle  which  is  greatly  exaggerated  in  the 
presence  of  hypersesthesia  of  the  posterior  urethra  incidental  to  in- 
flammation or  reflex  irritation  of  this  structure.  So  vigorous  is  the 
spasmodic  contraction  of  the  muscles  constituting  the  physiological 
cut-off  that  actual  traumatism  of  the  prostate  results.  There  is  a 
marked  disturbance  of  the  circulation  and  not  only  an  active, hyperse- 
mia,  but  a  lessened  power  of  resistance  of  both  glandular  and  mus- 
cular structure  to  sources  of  infection. 

Irritative  and  inflammatory  affections  of  the  lower  bowel  produce 
reflex  irritation  of  the  vesical  neck  with  associated  hypersemia  of  the 
prostate.  The  hypersemia  and  spasm  may  be  so  severe  that  reten- 
tion of  urine  results.  This  is  observed  after  operations  about  this 
part  and  in  inflamed  hemorrhoids.  Rectal  tenesmus,  as  seen  in  cer- 
tain cases  of  dysentery  and  acute  proctitis,  is  apt  to  produce  some- 
what similar  conditions  affecting  the  prostate  and  vesical  neck.  In 
cases  of  chronic  disease  of  the  lower  bowel,  such  as  polypi,  stricture, 
tumors,  and  particularly  hemorrhoids,  passive  congestion  of  the 
prostate  results  from  obstruction  to  the  venous  circulation.  The 
author  has  observed  well-marked  enlargement  of  the  prostate  asso- 
ciated with  stricture  of  the  rectum  and  hemorrhoids,  and  has  seen  the 
prostatic  disturbance  completely  disappear  after  an  operation  on  the 
lower  bowel.  Constipation,  excessive  horseback  riding,  and  the 
modern  exercise  of  bicycle  riding,  are  efficient  causes  of  prostatic 
hyperaemia  in  some  cases. 

Hypersemia  of  the  prostate  exists  in  all  cases  of  strangury  pro- 
duced by  drugs.  Cantharides,  turpentine,  and,  it  is  said,  the  vari- 
ous balsamic  preparations  may  produce  this  condition.  Prostatic 
hyperaemia  rarely,  if  ever,  goes  on  to  acute  inflammation  idiopathi- 
cally.  Instrumental  interference  with  associated  trauma  and  sepsis, 
or  a  mixed  infection  from  posterior  urethritis,  is  usually  necessary  to 
precix)itate  acute  inflammation.  Obstructive  affections  of  the  urethra 
are  likely  to  produce  more  or  less  marked  prostatic  hyperaemia. 
Urethral  strictures  of  small  calibre  are  usually  associated  with  more 


346  LYDSTON — DISEASES  OF  THE  PKOSTATE. 

or  less  marked  engorgement  of  tlie  prostate.  Large-calibred  penile 
strictures  may  produce  prostatic  liypersemia  reflexly,  even  where  there 
is  no  appreciable  obstruction  to  the  passage  of  urine.  The  slightest 
degree  of  coarctation  in  the  bulbo-membranous  region  is  quite  likely, 
from  the  close  association  of  the  nervous  and  vascular  supply  of  the 
affected  part  with  that  of  the  prostate,  to  produce  circulatory  distur- 
bance in  the  latter  structure. 

Whether  or  not  chronic  hypersemia  of  the  prostate  may  be  the 
foundation  of  hypertrophy  of  the  organ  in  after-life  has  been  the 
subject  of  much  difference  of  opinion.  The  author  inclines  to  the 
affirmative,  as  will  hereafter  appear. 

Hypersemia  of  the  prostate  may  become  chronic.  Under  such 
circumstances  it  is  usually  of  a  passive  character,  and  is  generally 
associated  with  constipation  and  ungratified  sexual  desire.  Sexual 
excitement  is  the  most  important  factor  in  its  production,  and  it  is 
especially  likely  to  exist  in  masturbators.  This  form  of  chronic 
hypersemia  is  characterized  by  the  escape  of  prostatic  fluid  at  various 
times,  and  is  usually  supposed  by  the  patient  to  be  spermatorrhoea, 
while  to  the  profession  at  large  most  cases  are  classified  as  prostator- 
rhcea.  The  congestion  of  the  affected  organ  brings  about  hyperse- 
cretion, and  in  all  probability  a  relaxed  condition  of  the  mouths  of 
the  prostatic  ducts.  The  condition  might  be  classified  as  prostatic 
catarrh  were  it  not  for  the  quite  general  association  of  this  term  with 
true  inflammation.  Follicular  prostatitis  as  described  by  most  authors 
implies  this  result  of  hypersecretion,  and  appears  to  the  present  writer 
to  be  a  misnomer. 

The  principal  disturbances  from  this  form  of  prostatic  disease 
are  of  a  psychical  rather  than  physical  character. 

Symptoms. 

One  of  the  most  characteristic  symptoms  is  a  sense  of  fulness  in 
the  perineum  and  a  sensation  of  a  voluptuous  character  as  of  im- 
pending orgasm.  There  is  likely  to  be  a  sensation  of  fulness  in  the 
rectum  with  possibly  erotic  sensations  and  more  or  less  tenderness 
-during  the  evacuation  of  the  bowel.  An  urgent  desire  to  urinate 
is  almost  invariably  excited  by  the  act  of  defsecation.  There  may  be 
considerable  engorgement  of  the  prostate  without  much,  if  any, 
increase  in  the  frequency  of  micturition.  If,  however,  the  point  of 
departure  be  direct  or  reflex  irritation  or  inflammation  of  the  pos- 
terior urethra,  frequent  and  painful  micturition  is  an  inevitable  re- 
sult. Even  in  cases  in  which  micturition  is  not  increased  in  fre- 
quency, the  patient  will  very  likely  complain  of  some  pain  and  a 


HYPERiEMIA  OF  THE  PROSTATE.  347 

bruised  sensation  in  the  perineum  following  the  act  of  micturition.  If 
the  hypereemia  be  long  continued,  "  prostatorrhoea"  is  likely  to  super- 
vene as  a  consequence  of  hypersecretory  activity  of  the  prostatic 
glands.  In  some  cases  the  floor  of  the  prostatic  urethra  becomes 
so  hypersensitive  that  seminal  emissions  are  frequent.  Rusty  or 
bloody  semen  is  occasionally  observed,  but  as  a  rule  this  symptom 
is  indicative  of  seminal  vesiculitis. 

Pain  during  the  paroxysmal  spasm  incidental  to  seminal  ejacula- 
tion is  a  quite  frequent  symptom.  Many  patients,  however,  will 
state  that  coitus  is  beneficial.  In  such  cases  it  is  very  safe  to  con- 
clude that  the  condition  of  the  prostate  is  one  of  simple  hypersemia. 
But  even  here  it  is  not  unusual  for  the  patient  to  experience  only 
temporary  relief  from  coitus.  Often  repeated  indulgence  results  in 
aggravation  of  the  symptoms.  Rectal  examination  may  elicit  some 
fulness  and  tenderness  of  the  prostate.  This  is  not  always  present, 
as  there  may  be  quite  a  degree  of  passive  hypergemia  without  any 
particular  increase  in  the  size  of  the  prostate.  This  symptom  is 
quite  apt  to  be  unreliable,  because  of  the  variability  of  the  size  of 
the  prostate  as  felt  per  rectum  and  the  varying  degrees  of  digital 
expertness  in  rectal  examinations.  Passive  hypersemia  of  the  pros- 
tate associated  with  circulatory  disturbance  in  the  lower  bowel,  or 
dependent  upon  a  gouty  or  rheumatic  diathesis,  is  occasionally  as- 
sociated with  hsematuria.  The  author  has  observed  a  number  of 
cases  of  hsematuria  with  the  expulsion  of  the  characteristic  fusiform 
clot  found  in  prostatic  hemorrhage,  in  which  he  was  unable  to  de- 
termine any  other  cause  than  a  condition  of  passive  prostatic  con- 
gestion, which  attention  to  the  assumed  etiological  factors  very 
speedily  relieved,  measures  to  relieve  portal  congestion  having  been 
especially  efl&cacious.  This  point  is  worthy  of  consideration  in  cases 
of  hsematuria  of  obscure  origin. 

A  very  frequent  symptom  of  chronic  hypersemia  of  the  prostate  is 
a  discharge  of  the  characteristic  secretion  of  the  affected  organ  from 
the  urethra.  This  is  favored  by  sexual  excitement,  erotic  ideas  be- 
ing sufficient  in  some  cases  to  produce  it.  Under  such  circumstances 
it  is  associated  with  a  greater  or  less  amount  of  secretion  from  the 
urethral  glands,  the  secretion  of  the  latter  escaping  during  the  excite- 
ment, while  the  prostatic  secretion  afterward  comes  away  with  the 
escaping  urine.  It  is  most  frequently  observed  during  straining  at 
stool,  and  sufficient  secretion  may  escape  with  the  outflowing  urine  to 
produce  an  appreciable  deposit  in  this  fluid  when  allowed  to  stand. 
Very  often  no  discharge  of  the  prostatic  fluid  is  observed  excepting 
at  the  termination  of  the  act  of  micturition,  when,  according  to  the 
patient's   story,  the  urine  appears  to  be  decidedly  milky.     These 


348  LIDSTON — ^DISEASES  OF  THE  PROSTATE. 

patients  are  of  all  others  the  most  likely  to  become  the  victims  of  the 
quack,  and  they  constitute  by  far  the  larger  proportion  of  cases  of 
alleged  spermatorrhoea.  Associated  with  the  local  difficulty  is  more 
or  less  hypochondria,  perhaps  verging  upon  melancholia.  The  pa- 
tient occupies  himself  very  industriously  in  magnifying  every  symp- 
tom, real  or  imaginary,  of  which  he  may  chance  to  be  the  victim. 
The  unstable  condition  of  the  patient's  mind  is  a  sufficient  explana- 
tion of  the  profound  influence  which  quacks  and  quack  literature  are 
likely  to  have  upon  him.  Associated  with  the  so-called  prostator- 
rhoea  may  be  more  or  less  vesical  irritation,  largely  neurotic  in  char- 
acter, and  perhaps  neuralgic  pains  in  the  urethra,  perineum,  groins, 
and  thighs.  The  majority  of  patients  complain  of  pain  in  the 
back  as  the  most  prominent  symptom  aside  from  the  urethral  dis- 
charge. 

Whenever  fluid  escapes  from  the  meatus  during  the  intervals  of 
micturition,  excepting  during  the  act  of  defsecation,  some  morbid 
condition  of  the  anterior  urethra  is  superadded  to  the  prostatic 
hyperemia.  The  prostatic  fluid  cannot  escape  unless  the  true 
sphincter  vesicae — i.e.,  the  membraneous  urethra  and  its  muscular  in- 
vestments— be  physiologically  relaxed,  or  the  prostate  be  mechani- 
cally squeezed  by  the  perineal  muscles  and  the  passage  of  hardened 
faeces. 

The  fluid  which  escapes  during  sexual  excitement  consists  of 
the  secretion  from  the  urethral  glands.  The  term  prostatorrhoea  has 
about  the  same  significance,  as  far  as  its  relation  to  the  affected  part 
is  concerned,  that  gleet  does  to  diseases  of  the  urethra.  It  is  a  term 
which  it  might  be  well  to  dispense  with  altogether,  excepting  with 
the  understanding  that  it  is  merely  a  symptom.  In  cases  of  simple 
chronic  hypersemia  of  the  prostate,  the  resulting  discharge  of  pros- 
tatic secretion  does  not  contain  inflammatory  elements,  being  made 
up  almost  entirely  of  prostatic  secretion,  mucus,  and  some  effete 
epithelial  cells.  There  may  be  present,  especially  after  sexual  excite- 
ment, a  certain  number  of  seminal  elements  which  have  escaped  from 
the  over-distended  vesiculse  seminales.  The  escape  of  semen  into 
the  prostatic  urethra  is  favored  by  a  relaxation  or  patulousness  of  the 
mouths  of  the  ejaculatory  ducts,  and  is  often  immediately  induced  by 
straining  at  stool.  The  seminal  elements  are  few  in  number  and 
their  presence  is  by  no  means  a  necessary  symptom.  Earely  indeed, 
are  they  sufficiently  abundant  to  warrant  the  use  of  the  term  sperma- 
torrhoea. No  matter  how  few  in  number  they  may  be,  however,  they 
are  hailed  with  delight  by  the  spermatorrhoea-seeking  quack,  and 
undue  importance  is  often  attached  to  their  presence  even  by  honest 
practitioners. 


HYPEE^MIA  OP  THE  PROSTATE.  349 


Treatment. 


The  first  principles  of  treatment  of  prostatic  liyperaemia  involve 
all  of  the  rules  of  genito-urinary  hygiene,  a  subject  which  can- 
not here  be  exhaustively  discussed.  Briefly,  the  urine  should 
be  rendered  unirritating  by  the  administration  of  bland  fluids,  of 
which  distilled  water  or  the  various  saline  mineral  waters  may  be 
taken  as  the  type.  Alkaline  remedies  may  be  administered  where 
simpler  measures  are  not  sufficient  to  neutralize  urinary  acidity. 
The  diet  should  be  unstimulating,  milk  being  the  ideal  form  of  ali- 
ment for  reasons  too  thoroughly  understood  to  require  expatiation. 
All  sources  of  sexual  excitation,  both  mental  and  physical,  should  be 
removed.  Exercise  should  be  restricted  and,  if  necessary,  prohibited 
altogether.  Athletic  feats,  bicycling,  horseback  riding,  and  climbing 
are  particularly  to  be  forbidden.  Climbing  exercises,  as  practised 
by  young  lads  and  some  athletes,  are  especially  injurious.  The 
danger  of  the  supervention  of  acute  inflammation  or  of  a  chronic 
condition  of  disease  should  be  impressed  upon  the  patient.  Instru- 
mentation of  the  urethra  is  in  a  general  way  to  be  avoided  in  acute 
hypersemia.  There  are  numerous  internal  remedies  which  are  ser- 
viceable in  prostatic  congestion.  Mercurial  and  saline  cathartics 
and  laxatives  are  especially  beneficial  as  tending  to  relieve  hepatic 
congestion,  and  thus  indirectly  to  remove  obstruction  to  the  pelvic  cir- 
culation. Ergot  and  the  fluid  extract  of  gossypium  are  of  undoubted 
value  as  directly  tending  to  correct  the  circulatory  disturbance.  The 
element  of  sexual  excitation  is  best  combated  by  the  administration 
of  the  bromides  in  combination  with  gelsemium.  Monobromide  of 
camphor,  hyoscyamus,  and  some  other  anaphrodisiacs  are  likely  to  be 
of  service.  Suppositories  of  ice  and  enemata  of  cold  water  are  often 
valuable.  Cold  sitz-baths  constitute  an  excellent  adjuvant.  In  pro- 
static hyperaemia  dependent  upon  ano-rectal  or  vesical  disease,  the 
treatment  should  necessarily  be  directed  to  the  relief  of  the  primary 
condition. 

In  cases  of  chronic  prostatic  hyperaemia  associated  with  so-called 
prostatorrhoea,  special  attention  should  be  paid  to  the  psychological 
disturbances  present.  It  is  rai;©ly  indeed  that  such  cases  come 
under  the  observation  of  the  reputable  practitioner  before  a  number 
of  quacks  have  been  consulted.  The  patient  is  thoroughly  imbued 
with  the  notion  that  he  has  spermatorrhoea  with  an  allied  train  of 
serious  nervous  disturbances,  and  last,  but  not  least,  he  believes  him- 
self to  he  impotent.  Instruction  in  sexual  physiology  and  hygiene  is 
absolutely  necessary  for  this  class  of  patients.  Particularly  must 
they  be  impressed  with  the  fact  that  they  are  not  losing  semen  in  the 


350  LYDSTON — DISEASES  OF  THE  PROSTATE. 

urine,  else  all  of  our  efforts  will  be  set  at  naught  by  the  morbid  con- 
dition of  the  patient's  mind.  By  far  the  larger  proportion  of  cases 
will  be  found  to  be  suffering  from  constipation.  The  relief  of  this 
condition  in  most  instances  causes  the  prostatorrhoea,  which  is  the 
most  prominent  symptom  in  the  mind  of  the  patient,  to  disappear. 
Ergot  and  the  bromides  are  exceedingly  useful  internal  remedies. 
Hamamelis  and  hydrastis  are  likely  to  be  serviceable  from  their 
known  influence  over  unstriated  muscular  fibre  and  incidentally  by 
controlling  vascular  supply.  Tonics  are  very  likely  to  be  useful  in 
this  class  of  cases.  Various  preparations  of  strychnine,  iron,  and 
arsenic  and  the  mineral  acids  are  of  service.  The  occasional  passage 
of  the  cold  steel  sound  constitutes  a  most  valuable  local  measure  of 
treatment.  The  effect  of  instrumentation  is  to  a  certain  extent 
moral,  but  the  resulting  benefit  is  none  the  less  marked.  The  phy- 
sical effect  is  probably  the  restoration  of  local  vascular  tone  and  a 
relief  of  nervous  irritability.  Cold  sitz-baths  and  injections  of  cold 
water  into  the  rectum  constitute  a  valuable  adjuvant.  Counter-irri- 
tation of  the  perineum  is  likely  to  be  beneficial.  The  local  applica- 
tion of  astringents  directly  to  the  prostatic  sinus  may  be  alternated 
mth  the  insertion  of  the  steel  sound.  Nitrate  of  silver  in  mild 
solutions,  tannic  acid,  and  the  muriate  of  hydrastine  are  all  service- 
able drugs.  Soluble  bougies  containing  astringents  are  sometimes 
of  service.  The  local  treatment  in  prostatic  hypersemia  associated 
with  so-called  prostatorrhoea  is  very  similar  to  that  of  chronic  folli- 
cular prostatitis,  in  which  escape  of  prostatic  secretion  is  also  a 
symptom. 

Acute  Prostatitis. 

Acute  prostatitis  is  one  of  the  most  serious  and  painful  of  the 
acute  affections  to  which  the  genito-urinary  system  is  subject.  The 
condition  which  most  often  gives  rise  to  it  is  so  prevalent  that  the 
disease  is  quite  frequently  met  with.  Acute  prostatitis  with  associ- 
ated urinary  retention  was  recognized  many  years  ago  by  the  cele- 
brated French  surgeon,  Jean  Louis  Petit,  as  shown  in  his  posthumous 
works  ("OEuvres  posthumes  de  Chirurgie,"  par  Lesne,  Paris,  1774). 
It  is  a  noteworthy  fact  that  the  reputation  of  Petit  as  a  careful  clinical 
observer  is  borne  out  by  his  ideas  of  the  etiology  and  pathology  of 
acute  prostatitis,  which  were  in  the  main  in  accord  with  the  more 
modern  views  upon  the  subject.  He  stated  that,  according  to  his 
observations,  nearly  all  patients  affected  by  acute  prostatitis  had 
suffered  from  a  more  or  less  recent  attack  of  gonorrhoea,  which  in 
most  instances  had  not  been  methodically  treated. 


ACUTE   PKOSTATITIS.  351 

In  a  general  way,  it  may  be  asserted  that  while  acute  prostatitis 
may  or  may  not  be  preceded  by  hypersemia  of  greater  or  less  dura- 
tion, which  acts  as  a  predisposing  factor,  the  disease  is  very  rarely  a 
primary  affection  excepting  it  be  of  traumatic  or  chemical  origin,  or 
the  result  of  pyogenesis  secondary  to  constitutional  infection,  such 
as  exists  in  variola  and  parotiditis.  As  usually  met  with  it  is  a  com- 
plication, not  a  primary  disease.  The  profound  local  and  constitu- 
tional disturbance  resulting  in  a  large  proportion  of  cases  of  acute  in- 
flammation of  the  prostate,  and  especially  in  those  forms  in  which 
suppuration  results,  are  entirely  disproportionate  to  the  size  and 
physiological  importance  of  the  organ  involved.  The  affected  struc- 
ture, however,  is  exceedingly  sensitive  from  its  abundant  supply  of 
general  and  special  sensory  nerve  filaments,  and  assumes  a  position  of 
great  importance  by  virtue  of  its  abundant  sympathetic  nerve  supply 
and  its  consequent  intimate  relations  with  the  various  organs  involved 
in  the  functions  of  organic  life.  In  this  respect  it  resembles  rather 
strongly  its  colaborer  in  the  generative  function,  the  testis.  Xiike  the 
latter  organ,  it  is  surrounded  by  a  tough  resisting  capsule  and,  in 
addition,  by  an  environment  of  firm  resisting  structures.  As  a 
consequence  of  this  anatomical  arrangement  the  organ  is  very  un- 
yielding to  the  pressure  of  exuded  inflammatory  products,  or  of 
exaggerated  blood  supply.  This,  in  connection  with  the  exceedingly 
sensitive  and  abundant  nerve  filaments,  is  sufficient  to  explain  the 
severe  pain,  nervous  depression,  and  other  constitutional  disturbances 
incidental  to  inflammation  of  the  organ.  The  same  anatomical  con- 
ditions of  nervous  and  vascular  supply,  and  the  close  proximity  of  the 
affected  organ  to  the  rectum,  explain  the  disturbances  referable  to 
the  latter  viscus  in  the  course  of  acute  prostatitis. 

Etiology. 

The  causes  of  acute  prostatitis,  as  outlined  by  some  authors,  con- 
stitute a  rather  complex  subject,  presenting  many  elements  of  im- 
practicality  and  sources  of  confusion.  Practical  clinical  experience 
shows  that  while  many  predisposing  elements  necessarily  enter  into 
consideration,  acute  prostatitis  is  precipitated  in  the  majority  of 
instances  by  causes  of  rather  a  common  character.  Thus  nearly  all 
cases  are  found  to  be  due  to  direct  extension  of  acute  inflammation 
of  the  urethra,  usually  of  gonorrheal  origin.  Other  factors  are  to  be 
taken  into  consideration,  it  is  true,  in  those  cases  in  which  suppura- 
tion results,  because  of  the  clinical  fact  that  in  by  far  the  larger 
proportion  of  cases  of  acute  prostatitis  suppuration  does  not  follow. 
The  author  bases  this  broad  assertion  upon  the  view  that  in  the 


352  LTDSTON — DISEASES  OF  THE  PEOSTATE. 

larger  proportion  of  cases  of  acute  inflammation  of  the  prostate  the 
process  is  limited  to  the  glandular  structures  of  the  organ,  and  par- 
takes of  the  same  characters  as  the  original  gonorrhoeal  infection  with 
certain  modifications  due  to  anatomical  and  physiological  pecuharities 
of  the  affected  part.  Mechanical  interference  with  the  prostate,  in- 
cidental to  the  treatment  of  acute  or  chronic  bladder  difiiculties  or 
for  the  purpose  of  exploration,  is  responsible  for  most  of  the  remain- 
ing cases.  Even  here  we  have  gonorrhoeal  or  other  infection  of  the 
urethra  as  the  principal  etiological  factor,  the  instrument  used  acting 
merely  as  a  carrier  of  infection,  or  establishing  a  locus  minoris  resis- 
tentioe  by  injuring  the  prostatic  urethra.  The  experience  of  every 
practical  surgeon  has  shown  that  in  every  case  of  urethral  disease, 
acute  or  chronic,  more  particularly  in  the  acute  forms  of  inflamma- 
tion, the  patient  is  constantly  liable  to  the  development  of  an  acute 
inflammation  of  the  prostate. 

In  view  of  the  careless,  routine,  and  often  over-vigorous  treat- 
ment of  gonorrhoea,  to  say  nothing  of  the  vicious  self-imposed  hy- 
gienic conditions  of  the  patient,  it  is  a  matter  of  surprise  that 
prostatic  complications  do  not  occur  in  every  case  of  gonorrhoeal  in- 
fection. That  patients  with  virulent  urethritis  of  specific  origin 
should  escape  prostatic  complications,  is  to  the  mind  of  the  author 
somewhat  remarkable,  when  we  consider  the  high  degree  of  infec- 
tiousness of  the  various  microbial  organisms  and  their  products  char- 
acteristic of  that  typically  mixed  infection  known  as  gonorrhoea. 
Acute  prostatitis  may  be  developed  by  very  trifling  causes  during  the 
course  of  a  gonorrhoea.  These  causes  may  consist  in  ill-advised 
attempts  to  cure  the  disease,  or  in  misconduct  on  the  part  of  the 
patient. 

The  disease  is  especially  liable  to  follow  indiscretions  or  excite- 
ment of  a  sexual  character.  Alcoholic  and  dietetic  excesses  and 
over-exertion  play  a  most  important  role  in  developing  this  complica- 
tion in  the  course  of  a  gonorrhoea. 

As  a  preliminary  to  the  discussion  of  the  etiology  of  acute  pros- 
tatitis in  detail,  a  presentation  of  the  various  etiological  factors  as 
accepted  by  various  authorities  may  be  serviceable.  The  etiological 
table  of  Segond  is  one  of  the  most  elaborate  schematic  outlines  of 
etiological  possibilities  that  have  thus  far  been  presented  in  connection 
with  acute  prostatitis.  In  considering  this  table,  the  practitioner 
should  understand  that  it  will  prove  of  little  value  unless  the  various 
causes  outlined  therein  be  assigned  their  true  importance  as  etiologi- 
cal factors.  This  being  understood,  the  table  itseK  will  enable  us 
to  reduce  the  etiology  of  acute  prostatitis  to  a  comparatively  simple 
basis. 


ACUTE   PEOSTATITIS. 


353 


Segond's  table  is  as  follows : 

Acute  Prostatitis. 


I.  From     indirect 
causes. 


II.  From  direct 

mechanical  - 
causes. 


III.  From 


irritation. 


Exposure  to  cold  {Prostatites  a  frigore).  Metastasis,  puru- 
lent infection  from  mumps,  variola,  etc. 

f  {a)  Traumatic  prostatitis,  due  to  contusions  from  without 
inward,  produced  by  falls,  blows,  horseback  riding,  etc. 

{b)  Contusions  from  within  outward,  produced  by  forci- 
ble injections,  or  rough  instrumentation. 

(c)  Wounds  from  without  inward,  produced  by  pelvic 
fractures,  falls  on  pointed  objects,  gun-shot  wounds  or 
surgical  interference  with  the  organ. 

{d)  Wounds  from  within  outward,  produced  by  instru- 
mentation with  or  without  resulting  false  passages,  or 
produced  by  the  stylet  escaping  from  the  eye  of  the 
catheter  during  the  introduction  of  that  instrument. 
Any  variety  of  wound  of  the  urethra  produced  by 
surgical  or  accidental  traumatism. 

f  Cauterization  with  nitrate  of  silver,  caustic  or  astringent 
injections. 
Cantharides  internally,  excessive  indulgence  in  alcoholics, 
overdoses  of  the  balsams, 
direct   |  Vesical  or  prostatic  calculi,  or  other  foreign  bodies  in  the 
■{       prostatic  urethra. 

The  retained  catheter  or  bougie. 

Horseback  riding,  over-exertion  in  walking  or  running, 
constipation,  excessive  purgation,  sedentary  habits, 
varicosity  of  the  rectal  veins,  masturbation  and  sexual 
excess,  nocturnal  pollutions,  prostatic  hypertrophy. 


rV".  From    propa- 
gation. 


f  By  continuity. 


i  Gonorrhoea,    cystitis,   i 
\       throtomy,  or   other  o 


I 

[  By  contiguity. 


the  urethra. 


internal  ure- 
perations  on 


Hemorrhoids,     rectal    stricture    or 
neoplasm,    proctitis,    and    fistula 


As  a  broad  proposition,  it  is  safe  to  assert  tbat  by  far  the  ma- 
jority of  cases  of  acute  prostatitis  are  due  to  infection  in  some  form. 
This  being  accepted,  it  is  obvious  tliat  many  of-  the  causes  outlined 
in  Segond's  table  are  factors  secondary  and  subordinate  to  infection. 
If  we  add  to  the  cases  produced  by  infection  the  relatively  much 
smaller  number  of  cases  produced  by  mechanical  and  chemical  vio- 
lence, we  have  practically  included  all  the  causes  of  acute  prostatitis. 
It  is  to  be  understood  also  that  in  many  instances  chemical  and  trau- 
matic injuries  of  the  prostate  induce  acute  prostatitis  solely  by  carry- 
ing infection  or  by  opening  up  avenues  for  the  absorption  of  infective 
material.  It  is  of  course  a  difficult  matter  to  separate  these  cases 
from  those  in  which  the  inflammation  is  immediately  due  to  trau- 
matic or  chemical  causes.  Generally  speaking,  however,  it  is  safe  to 
assume  that  in  the  cases  in  which  suppuration  occurs,  chemical  or 
traumatic   injury  to  the  prostate,  if  it  exists  at  all,  acts  as  a  factor 

subordinate  to  infection.* 
Vol.  I.— 23 


354 


LYDSTON — DISEASES  OP  THE  PROSTATE. 


The  following  rather  simple  classification  may  give  a  somewhat 
clearer  insight  into  the  etiology  of  acute  prostatitis  than  either  the 
elaborate  etiological  table  or  the  general  remarks  thus  far  presented : 


Predisposing 

causes. 


Exciting  causes  . 


Acute    Prostatitis. 

iThe  gouty  and  rheumatic  diatheses. 
Alcoholic  and  dietetic  excesses. 
Exposure  to  cold. 

f  Highly  acid  urine. 

Hypersemia  from  whatever  cause. 

Acute  or  chronic  urethritis. 

Stricture. 

Chronic  prostatic  disease. 

Cystitis  or  other  vesical  diseases. 
Local -i  Vesical  calculi. 

Eectal  and  anal  disease. 

Portal  obstruction. 

Constipation  or  diarrhoea. 

Over-exertion,  and  such  forms  of 
exercise  as  bicycling  and  horse- 
back riding. 

'  Gonorrhoea  and  its  congeners — by  direct  extension,  or 
indirectly  by  absorption  of  infectious  materials — i.e., 
germs  or  their  products. 

Traumatism — surgical  or  accidental,  chemical  or  me- 
chanical. 

Sexual  indulgence. 

Chemical  irritation. 

Vesical  or  prostatic  calculi. 

Transportation  of  infectious  material  by  deep  injections  or 
instrumentation . 


Exposure  to  cold  unassociated  with  a  gouty  or  rheumatic  diathe- 
sis is  not,  in  the  opinion  of  the  author,  a  very  efficient  cause  of  acute 
prostatitis,  unless  some  source  of  infection  be  present.  That  pro- 
found disturbanc^e  of  the  circulation  of  the  prostate  may  result  from 
chilling  of  the  surface  of  the  body,  particularly  when  the  lower  ex- 
tremities are  exposed  to  cold  and  wet,  is  admitted.  That  this  will 
result  in  acute  prostatitis  in  cases  in  which  some  source  of  infection 
is  not  alread}^  present,  cannot,  however,  be  accepted  in  the  light  of 
our  present  knowledge  of  the  germ  origin  of  disease.  Given,  how- 
ever, the  existence  of  infection  of  the  urethra,  prostate,  or  bladder, 
the  disturbance  of  the  circulation  incidental  to  exposure  may  develop 
a  lessened  degree  of  resistance  to  germ  infection  on  the  part  of  the 
prostate  which  may  result  in  acute  prostatitis  with  or  without  the 
occurrence  of  abscess.  Cases  are  frequently  met  with  in  which  pa- 
tients presumably  have  had  no  infectious  disease  of  the  genito-uri- 
nary  tract,  but  in  whom  a  certain  degree  of  irritation  of  the  neck  of 
the  bladder  results  from  exposure  to  cold.  It  will  be  found,  how- 
ever, that  in  such  cases  there  usually  exists  a  more  or  less  marked 


ACUTE   PROSTATITIS.  355 

tendency  to  rheumatism  or  gout.  Many  of  tlie  cases  of  so-called 
prostatitis  consist  merely  in  an  irritation  of  the  mucous  membrane 
of  the  prostatic  urethra,  due  to  the  development  of  an  excess  of  uric 
acid  crystals  in  the  urine  incidental  to  chilling  of  the  surface  of  the 
body.  That  such  cases  are  frequently  diagnosed  as  acute  prostatitis, 
the  author  is  fully  aware.  In  the  majority  of  such  cases,  however, 
not  only  is  there  an  entire  absence  of  true  inflammation  of  the  pros- 
tate, but  there  is  no  inflammation  of  the  prostatic  urethra  itself,  the 
condition  being  merely  one  of  local  irritation  of  a  highly  sensitive 
nervous  structure  resulting  from  the  presence  in  the  urine  of  irritating 
crystals  of  uric  acid  and  possibly  of  oxalate  of  lime.  The  prolonged 
contact  of  the  i^erineum  with  a  cold  and  damp  surface  is  said  to  be  an 
efficient  cause  of  acute  prostatitis.  While  this  may  be  a  cause  of  sec- 
ondary importance,  in  all  probability  it  is  not  capable  of  inducing 
acute  inflammation  of  the  organ  in  question  unless  some  source  of 
infection  exists.  The  gouty  and  rheumatic  diatheses,  either  alone  or 
associated  with  exposure  to  cold  and  wet,  may  develop  prostatic  irri- 
tation and  possibly  precipitate  true  acute  prostatitis  in  cases  in  which 
infection  already  exists.  The  influence  of  gout  and  rheumatism  is 
exerted  not  only  in  the  direction  of  aberration  of  the  quality  and  quan- 
tity of  urinary  solids  and  an  alteration  of  urinary  reaction,  but  also 
in  the  production  of  an  intrinsic  irritabilitj^  of  nervous  and  vascular 
structures,  by  virtue  of  which  they  react  more  promptly  and  markedly 
to  sources  of  irritation.  It  is  obvious  that  an  individual  who  is  ex- 
posed to  psychical  or  physical  causes  of  sexual  excitement  is  espe- 
cially predisposed  to  the  development  of  acute  jjrostatic  inflammation 
in  the  presence  of  infectious  genito-urinary  disease.  It  is  certain  that 
if  this  particular  predisposing  cause  could  be  entirely  eliminated  in 
the  majority  of  cases  of  acute  or  chronic  genito-urinary  disease,  the 
proportion  of  cases  in  which  prostatitis  develops  as  a  complication 
would  be  very  materially  reduced.  Acute  or  chronic  disease  of  the 
urethra  constitutes  a  constant  menace  to  the  prostate.  Stricture  of 
the  urethra,  which  seems  to  have  been  entirely  overlooked  by  Segond, 
is  worthy  of  consideration  in  this  regard.  These  conditions  of  acute 
or  chronic  inflammation  may  produce  acute  prostatitis  from  compara- 
tively trifling  exciting  causes.  It  is  obvious  that  chronic  prostatic 
disease,  especially  those  forms  in  which  a  focus  of  infection  exists  in 
the  prostatic  urethra  or  bladder,  are  likely  to  be  complicated  by  acute 
prostatitis.  Especially  is  this  true  if  traumatic  interference,  in  the 
form  of  violent  or  often-repeated  catheterization,  be  added  as  an  ex- 
citing cause.  Acute  i)rostatitis  or  para-i)rostatitis  is  a  rather  fre- 
quent complication  of  prostatic  hypertrophy.  What  has  been  said  of 
acute  and  chronic  disease  of  the  prostate  apx)lies  equally  to  cystitis. 


356  LYDSTON — DISEASES  OF  THE  PEOSTATE. 

The  infectious  products  of  inflammation  of  the  bladder  may  at  any- 
time, whether  under  the  exciting  influence  of  traumatism  or  through 
the  medium  of  a  secondary  infection  of  the  prostate  and  prostatic 
urethra,  produce  acute  prostatitis. 

Rectal  and  anal  disease  exert  so  profound  an  influence  over  the 
vascular  and  nervous  supply  of  the  prostate  that  their  importance  as 
etiological  factors  predisposing  to  acute  inflammation  of  the  organ 
is  by  no  means  surprising.  Physical  exertion,  particularly  that  in- 
volved in  walking,  running,  lifting,  bicycling,  and  other  forms  of 
athletic  exercises,  in  which  more  or  less  strain  is  brought  to  bear 
upon  the  perineum,  tends  to  produce  an  irritable  and  hypersemic 
condition  of  the  prostate,  in  the  presence  of  which  any  source  of  in- 
fection is  apt  to  manifest  itself  in  the  form  of  acute  inflammation  of 
the  organ.  In  by  far  the  majority  of  cases  of  acute  prostatitis  there 
exists  some  urethral  source  of  infection,  either  patent  or  obscure,  as 
a  direct  exciting  cause  of  the  acute  inflammation.  True  suppurative 
inflammation  of  the  urethra  is  not,  however,  absolutely  necessary  in 
order  that  infection  by  germs  or  germ  products  may  occur.  Thus 
the  infection  may  consist  of  the  products  of  decomposing  urine,  or 
the  secretions  of  urethral  or  prostatic  catarrh,  confined  behind  some 
obstruction  of  the  urethra,  such  as  is  afforded  by  prostatic  hyper- 
trophy or  stricture  of  the  canal.  The  cause  is  likely  to  be  a  recent 
gonorrhoea  of  an  acute  virulent  type,  but  the  infective  inflammation 
may  be  subacute  or  chronic.  Simple  urethritis,  acute  or  chronic, 
presents  a  secretion  teeming  with  germs  and  their  products,  which 
may  at  any  time  produce  acute  inflammation  of  the  prostate.  It 
must  be  remembered  in  this  connection  that  it  is  probably  the  mixed 
character  of  the  infection  which  is  in  all  cases  responsible  for  the 
cases  in  which  suppuration  of  the  prostate  or  peri-prostatic  tissues 
occurs. 

Laying  aside  the  cases  of  acute  follicular  prostatitis — i.e.,  poste- 
rior urethritis  occurring  in  the  course  of  acute  or  chronic  gonorrhoea, 
the  pus  microbe  and  its  products  are  responsible  for  prostatic  com- 
plications. It  is  safe  to  assert  that  in  most  of  the  cases  of  acute 
prostatitis,  an  area  of  suppuration  or  bacterial  infection  exists  in  the 
deep  urethra.  The  cause  may  consist  of  a  suppurative  or  chronic 
infective  inflammation  of  the  bulbous  or  bulbo-membranous  region. 
These  conditions  existing,  the  slightest  traumatism  or  the  occurrence 
of  active  hypersemia  may  at  any  time  produce  an  acute  and  violent 
inflammation  of  the  prostate.  One  of  the  most  frequent  causes  is  the 
mechanical  disturbance  of  the  prostate  incidental  to  sexual  inter- 
course. During  the  occurrence  of  the  venereal  orgasm  the  muscular 
tissues  of  the  perineum,  and  incidentally  of  the  prostate,  act  very 


ACUTE  PEOSTATITIS.  857 

mucL.  upon  the  principle  of  the  bulb  of  the  ordinary  Davidson  syringe. 
The  spasmodic  contraction  incidental  to  the  orgasm  alternates  with 
relaxation,  during  which  the  deep  perineal  muscles  and  the  prostate 
probably  exert  what  may  be  termed  an  aspirating  effect  upon  the 
urethra.  The  superfluous  semen  is  drawn  back  into  the  deep  urethra 
preparatory  to  the  occurrence  of  the  spasmodic  muscular  contraction 
by  means  of  which  the  last  few  drojjs  of  semen  are  to  be  expelled  into 
the  urethra  and  thence  into  the  vagina.  During  the  aspiration  of  the 
semen  into  the  deep  urethra,  any  infectious  materials  which  may 
exist  in  the  anterior  portion  of  the  canal  are  forcibly  drawn  into  the 
deeper  parts,  where  they  produce  acute  infection.  This,  while  pri- 
marily an  acute  follicular  prostatitis,  may  be  followed  at  any  time, 
and  perhaps  within  a  very  short  period,  by  acute  diffuse  inflamma- 
tion and  possibly  abscess  of  the  prostate.  It  is  a  matter  of  common 
observation  that  patients  presenting  themselves  with  acute  prostatitis 
in  the  course  of  gonorrhoea,  confess  to  sexual  indulgence  or  the  occur- 
rence of  a  nocturnal  emission  as  the  immediate  exciting  cause.  In 
the  opinion  of  the  author,  the  foregoing  constitutes  a  logical  explana- 
tion of  its  occurrence. 

In  quite  a  proportion  of  cases,  infection  of  the  prostate  in  the 
course  of  gonorrhoea  or  urethritis  is  a  result  of  deep  injections  or  the 
passage  of  instruments.  While  it  is  true  that  in  some  instances  the 
exciting  cause  would  seem  to  be  a  high  degree  of  chemical  irritation 
produced  by  the  injection,  it  is  probable  that  in  by  far  the  larger 
proportion  of  instances  in  which  the  prostatitis  can  fairly  be  attrib- 
uted to  the  use  of  injections,  the  fluid  so  used  is  only  indirectly 
responsible  for  the  occurrence  of  the  prostatitis,  inasmuch  as  it  serves 
merely  as  a  carrier  of  germ  infection.  It  is  probable  that  the  in- 
jection of  pure  water  would  be  equally,  if  not  more,  effective  in  this 
respect.  It  has  been  the  experience  of  the  author  that  the  frequency 
of  prostatic  comj^lications  is  directly  proportionate  to  the  vigor  with 
which  the  treatment  of  acute  gonorrhoea  is  pursued.  Some  of  the 
worst  cases  coming  under  observation  are  due  to  the  passage  of  in- 
struments for  the  relief  of  retention,  or  for  the  treatment  of  the 
urethritis.  Soluble  bougies  and  deep  urethral  irrigation,  used  during 
the  acute  stages  of  urethral  inflammation,  have  been  responsible  for 
a  large  number  of  cases.  The  soluble  bougie  or  the  tube  used  in 
deep  irrigation  acts  as  the  carrier  of  germ  infection  which  the  in- 
jected solution  is  too  weak  to  destroy.  Then,  too,  we  have  the  abrad- 
ing effect  of  the  instrument  or  soluble  bougie  upon  already  degener- 
ated and  readily  removable  epithelium.  This  opens  up  avenues  of 
infection  which  otherwise  might  possibly  never  occur. 

The  excessive  use  of  terebinthinate  and  balsamic  preparations  has 


358  LYDSTON — DISEASES  OF  THE   PROSTATE. 

been  said  to  cause  prostatitis.  It  is  possible  that  in  very  large  toxic 
doses  these  drugs,  in  combination  witli  an  already  existing  infection 
of  tlie  deep  urethra,  may  be  operative  in  producing  acute  inflamma- 
tion, but  under  no  other  circumstances.  Cantharides  in  poisonous 
doses  produces  inflammation  of  the  prostate  in  common  with  all  the 
other  structures  composing  the  genito-urinary  tract. 

In  concluding  the  subject  of  the  etiology  of  acute  prostatitis,  the 
author  desires  to  emphasize  the  paramount  importance  of  infection 
as  a  factor  in  the  etiology  of  the  disease,  and  to  insist  on  the  sub- 
ordinate character  of  by  far  the  larger  proportion  of  the  causes  enu- 
merated not  only  in  the  table  of  Segond,  but  in  the  much  simpler 
etiological  classiflcation  already  suggested.  A  further  practical  point 
of  great  importance  is  the  clinical  fact  that,  given  an  acute  or  chronic 
source  of  infection,  and  especially  the  former  yevy  slight  interference 
with  the  urethra  and  bladder  may  serve  to  precipitate  an  acute  in- 
flammation and  perhaps  abscess  of  the  prostate. 

VAEIETrES. 

Acute  prostatitis  presents  itself  in  several  forms  according  to  the 
method  of  causation  and  the  structures  to  which  the  acute  inflamma- 
tion is  mainly  localized.  Without  the  slightest  disposition  to  be  dog- 
matic in  the  matter  of  classification,  the  author  inclines  to  the  view 
that  from  a  clinical  standpoint  the  following  forms  of  acute  prostatitis 
are  capable  of  a  clinical  differentiation  which  is  of  vital  importance 
in  the  study  and  management  of  such  cases. 

A.  Follicular  or  jMrenchymatous  prostatitis,  having  its  point  of  de- 
parture in  a  posterior  urethritis  due  to  extension  or  transference  of 
infection  to  the  deep  urethra. 

B.  Diffuse  prostatitis,  usually  presenting  itself  as  a  consequence  of 
extension  of  the  acute  follicular  form.  It  may,  however,  occur  as  a 
primary  condition.  The  presence  and  degree  of  interstitial  inflam- 
mation in  the  diffuse  form  of  the  disease  depend  upon  the  method  of 
causation,  i.e.,  whether  it  is  due  to  traumatism,  to  extension,  or  to 
lymphatic  infection.  This  may  be  associated  with  localized  or  dis- 
seminated pyogenic  infection. 

C.  Prostatitis  loith  Circumscribed  Suppuration. — Acute  suppurative 
prostatitis,  due  to  extension  of  urethral  inflammation,  infection  from 
local  absorption,  or  infection  through  the  lymphatics  or  the  blood- 
vessels. 

D.  Prostatitis  with  Disseminated  Foci  of  Suppuration  (Miliary  Ab- 
scesses).— ^In  all  forms  of  prostatitis  associated  with  suppuration  more 
or  less  diffuse  interstitial  inflamn^ation  is  invariably  present. 


ACUTE  PEOSTATITIS.  '  359 

E.  Para-prostatitis. — This  is  usually  but  not  necessarily  followed 
by  abscess,  and  is  associated  with  one  or  the  other  of  the  foregoing 
forms. 

The  basis  for  classification  A  is  due  to  the  belief  of  the  author 
that  the  most  important  ultimate  anatomical  element  of  the  prostate 
is  the  secreting  glandular  tissue.  According  to  this  view  the  glands, 
ducts,  and  follicles  of  the  organ  constitute  the  true  parenchyma.  The 
acute  follicular  or  parenchymatous  form  of  the  disease  embraces  most 
of  the  cases  of  so-called  acute  posterior  urethritis,  and  varies  in  se- 
verity from  an  involvement  of  the  follicles  alone  to  that  of  all  the 
secreting  structures  of  the  organ.  Indeed,  it  is  the  opinion  of  the 
author  that  the  acute  inflammation  of  the  prostatic  urethra  in  these 
cases  is  relatively  unimportant  in  the  pathological  ensemble,  save  as 
the  point  of  departure  of  the  prostatic  inflammation.  Most  of  these 
cases  should  be  classified  as  acute  follicular  or  parenchymatous  pros- 
tatitis. In  practically  all,  if  not  actually  in  all,  of  the  cases  of  so-called 
acute  posterior  urethritis  from  gonorrhoea  or  other  source  of  mixed  in- 
fection, the  inflammation  of  the  mucous  membrane  of  the  deep  urethra 
is  but  a  small  part  of  the  morbid  condition  resulting  from  such  in- 
fection. The  author  cannot  conceive  of  an  acute  inflammation  of 
infectious  origin  which  limits  itself  to  the  mucous  membrane  of  the 
posterior  urethra.  A  few  subacute  and  chronic  cases  possibly  are  met 
with  in  which  the  bulbo-membranous  region  is  involved  without  ex- 
tension or  transference  to  the  prostatic  urethra.  It  is  the  belief  of  the 
writer,  however,  that  in  all  cases,  whether  acute  or  chronic,  in  which 
the  prostatic  portion  of  the  urethra  is  involved,  the  glandular  elements 
of  the  prostate  become  affected  sooner  or  later.  In  acute  cases  of 
inflammation  extending  beyond  the  bulbo-membranous  junction,  the 
author  does  not  believe  that  the  glandular  elements  of  the  prostate  can 
possibly  escape  involvement.  It  is  certainly  open  to  argument  whether 
or  not  the  consideration  of  so-called  posterior  urethritis  as  an  acute 
or  chronic  follicular  inflammation  of  the  prostate,  rather  than  a 
disease  of  the  urethra  per  se,  might  not  be  of  great  practical  clinical 
importance,  as  explaining  the  extreme  obstinacy  of  the  disease 
and  the  impossibility  of  curing  it  completely  by  applications  to 
the  small  and  unimportant  infected  area  presented  by  the  mucous 
membrane  lining  the  prostatic  urethra.  Looking  at  posterior  ure- 
thritis from  this  standpoint,  the  question  might  arise  whether 
deep  injections  of  astringents  may  not  defeat  the  very  object  which 
the  practitioner  strives  to  attain  in  such  cases,  by  impeding  drainage 
from  the  glandular  elements  and  ducts  of  the  prostate  constituting 
the  principal  seat  of  the  infectious  inflammation.  Associated  with 
these  cases  there  is  usually  more  oi-  loss  involvement  of  the  inter- 


360  LYDSTON — DISEASES  OF  THE  PKOSTATE. 

stitial  tissue  surrounding  the  ducts  and  glands  of  tlie  organ,  the 
resulting  mechanical  conditions  depending  entirely  upon  the  degree 
of  involvement. 

From  a  clinical  standpoint,  there  would  seem  to  be  a  broad  line 
of  distinction  between  the  acute  cases  of  follicular  inflammation  from 
extension  of  infection  from  the  prostatic  urethra  and  cases  in  which, 
as  a  result  of  lymphatic  absorption  or  of  infection  of  an  abraded 
surface  produced  by  traumatism,  prostatic  or  peri-prostatic  abscess 
occurs.  On  the  one  hand,  we  have  a  case  presenting  primarily  all 
of  those  symptoms  characteristic  of  irritation  and  inflammation  of 
the  true  vesical  neck,  i.e.,  the  prostatic  urethra;  while,  on  the  other 
hand,  we  have  a  much  less  degree  of  vesical  irritability  with  the  de- 
velopment of  more  or  less  sudden  obstruction  to  the  outflow  of  urine. 
In  acute  follicular  inflammation  retention  of  urine  rarely  results,  ex- 
cepting in  cases  in  which  there  is  a  high  degree  of  interstitial  inflam- 
mation. So  frequent,  however,  is  the  association  of  retention  with 
the  occurrence  of  prostatic  abscess  that  the  latter  is  to  be  strongly 
suspected  in  cases  of  acute  prostatitis  in  Avhich  retention  of  urine  is 
a  prominent  factor. 

In  the  dift'use  form  of  the  disease  there  is  usually,  as  a  result  of 
extension  of  the  infectious  process  from  the  prostatic  urethra,  a  very 
severe  degree  of  glandular  inflammation.  Associated  with  this  is  a 
well-pronounced  involvement  of  the  interstitial  tissue.  In  these 
cases,  on  account  of  the  anatomical  conditions  already  outlined,  the 
local  pain  and  the  constitutional  symj)toms  are  much  more  marked 
than  in  the  acute  follicular  form.  The  diffuse  form  may  be  the  re- 
sult of  lymphatic  absorption,  in  which  pain,  rectal  tenesmus,  and 
urinary  obstruction  may  develop  without  any  preceding  vesical  irri- 
tability. Abscesses  may  or  may  not  occur  in  the  diffuse  variety  of 
acute  prostatitis.  When  they  do  occur  thej^  may  be  the  result  of  a 
general  infection  of  the  organ,  or  an  occluded  duct  or  follicle  may 
constitute  the  primary  focus  of  infection  which  subsequently  ruptures 
and  infects  the  surrounding  tissues  of  the  prostate. 

Acute  suppurative  prostatitis,  as  already  outlined  in  the  preceding 
classification,  may  occur  in  one  of  three  forms :  1.  Circumscribed 
abscess,  single  or  multiple.  These  abscesses  may  involve  any  par- 
ticular portion  of  the  tissue  of  the  prostate ;  may  be  of  considerable 
size,  and  one  or  more  may  coalesce,  forming  a  large  abscess  cavity. 

2.  Disseminated    suppuration    in    the   form   of    miliary    abscesses. 

3.  Abscess  of  the  peri-prostatic  tissue  with  or  without  suppuration 
in  the  prostate  proper.  While  usually  due  to  local  sources  of  infec- 
tion, any  of  these  forms  of  abscess  may  occur  as  a  result  of  general 
pyogenic  infection,  and,  as  shown  in  the  table  of  Segond,  may  result 


ACUTE   PROSTATITIS.  361 

from  such,  infectious  diseases  as  variola  and  mumps.  Some  cases  of 
abscess  are  primarily  due  to  extension  of  suppurative  inflammation, 
while  others  are  due  to  lymphatic  absorption  and  infection  of  the 
tissues  of  the  prostate.  In  some  instances,  in  all  probability,  one 
or  more  of  the  numerous  ducts  of  the  prostate  become  occluded 
by  the  inflammatory  swelling  incidental  to  virulent  inflammation, 
with  the  consequent  retention  of  infectious  pus  in  the  form  of  a 
small  abscess  cavity,  the  walls  of  which  are  composed  of  the  walls  of 
the  duct  or  the  follicle  involved.  Such  circumscribed  retention  ab- 
scesses constitute  foci  of  infection  of  the  surrounding  tissues,  and 
when  they  form  at  the  periphery  of  the  organ  they  may  rupture  into 
the  para-prostatic  tissue  with  the  resulting  formation  of  an  abscess 
in  this  situation. 

Disseminated  foci  of  suppuration  in  the  prostate  constitute  the 
variety  which  is  most  likely  to  occur  from  constitutional  infection. 
The  rupture  of  a  small  abscess,  however  small,  into  the  peri-pros- 
tatic  tissue  will  almost  inevitably  result  in  an  abscess  in  this  situa- 
tion. 

It  is  unnecessary  to  expatiate  upon  para-prostatitis,  inasmuch  as 
the  most  important  points  have  already  been  set  forth.  It  is 
sufficient  to  say  that  it  most  usually  occurs  as  a  secondary  factor  in 
one  or  the  other  of  the  foregoing  forms  of  acute  inflammation.  Sup- 
puration usually  occurs,  and  in  some  cases  its  extent  may  be  rather 
startling,  the  pus  burrowing  extensively  about  the  rectum.  Eeten- 
tion  of  urine  is  a  usual  concomitant  of  marked  cases. 

Prostatic  Abscess. — The  subject  of  acute  prostatic  abscess  hardly 
requires  consideration  independently  of  acute  prostatitis.  There  are 
several  points,  however,  in  connection  with  suppuration  of  the  pros- 
tate that  merit  special  attention.  Abscess  of  the  prostate  in  the 
course  of  hypertrophy  of  the  organ  is  much  more  frequent  than  is 
ordinarily  supposed.  It  may  occur  spontaneously  as  a  result  of  in- 
fection, although  this  is  extremely  rare.  Most  often  it  occurs  as  the 
direct  result  of  traumatism  inflicted  during  the  treatment  of  the  dis- 
ease, or  during  the  passage  of  the  catheter  for  the  relief  of  retention 
dependent  upon  it.  It  is  the  opinion  of  the  author  that  in  quite  a 
prox^ortion  of  cases  in  which  a  fatal  result  follows  retention  of  urine 
from  hypertrophied  prostate  necessitating  prolonged  and  frequent 
instrumentation  for  its  relief,  the  immediate  cause  of  death  is 
general  septic  or  pus  infection  incidental  to  suppuration  of  the  pros- 
tate induced  by  the  surgical  interference.  Several  cases  have  come 
under  the  observation  of  the  author  in  w]ii(;h  the  patient  developed 
the  constitutional  manifestations  of  sex)sis  and  finally  sank  into  a 
typhoid  condition  and  died,  as  a  consequence  of  extensive  prostatic 


362  LYDSTON— DISEASES  OF  THE  PROSTATE. 

and  peri-prostatic  abscess,  whicli  was  directly  traceable  to  bungling 
and  injudicious  attempts  at  catheterization.  In  some  of  these  cases 
the  resulting  abscess  is  of  a  subacute  or  chronic  character  and  is  of 
prolonged  duration.  Rupture  may  finally  occur  into  the  urethra, 
rarely  externally,  in  which  event  sudden  relief  of  the  obstructive 
symptoms  may  result.  It  is  a  noteworthy  fact  that  some  cases  of 
prostatic  abscess  occurring  in  the  course  of  enlarged  prostate  are 
ultimately  followed  bj'  great  benefit  to  the  primary  condition.  The 
destruction  of  the  prostatic  tissue  incidental  to  the  abscess  formation 
is  followed  by  cicatricial  contraction  and  a  marked  diminution  of  the 
mechanical  obstruction  incidental  to  the  enlargement  of  the  organ. 
In  some  instances,  however,  the  abscess  cavity  not  only  does  not  be- 
come obliterated,  but  remains  as  a  suppurating  pocket,  opening  more 
or  less  freely  into  the  lumen  of  the  urethra  and  giving  rise  to  succes- 
sive re-infections  of  the  posterior  urethra  and  bladder,  or  even  infec- 
tion of  the  anterior  portion  of  the  canal.  This  is  true  of  all  forms  of 
prostatic  abscess.  In  abscess  occurring  in  prostatic  hypertrophy  it 
is  interesting  to  note  the  marked  diminution  in  the  size  of  that  por- 
tion of  the  prostate  which  happens  to  be  the  seat  of  suppuration.  In 
a  case  which  the  writer  has  recentlj^  seen  an  abscess  in  the  right  lobe 
of  the  prostate,  in  a  gentleman  of  middle  age  suffering  with  prostatic 
hypertrophy,  has  produced  so  much  shrinkage  of  the  affected  struc- 
ture that  it  is  hardly,  if  at  all,  larger  than  the  normal,  while  the  op- 
posite side  is  still  markedly  hypertrophied  and  indurated. 

The  occasional  occurrence  of  prostatic  abscess  in  prostatiques 
constitutes  a  very  practical  point  in  the  studj"  of  prostatic  hyper- 
trophy. It  is  by  no  means  unusual  for  the  first  severe  symptoms  of 
prostatic  obstruction  in  old  men  to  occur  coincidentally  with  the  for- 
mation of  the  prostatic  abscess.  Inasmuch  as  after  evacuation  of 
the  abscess  the  symptoms  practically  disappear,  an  erroneous  diag- 
nosis is  quite  easily  made,  the  case  being  considered  as  ah  initio  one 
of  prostatic  suppuration. 

That  a  fatal  result  may  follow  prostatic  abscess  not  only  in  old  but 
in  young  subjects  must  be  borne  in  mind.  A  case  recently  came  un- 
der my  observ'ation  in  which  a  j^oung  man,  thirty-five  years  of  age, 
was  permitted  to  die  of  what  was  supposed  to  be  typhoid  fever,  but 
which,  as  the  autopsy  showed,  was  sepsis  due  to  a  large  prostatic 
abscess.  It  is  well  in  all  cases  of  serious  prostatic  disease,  to  keep 
a  close  watch  for  the  constitutional  symptoms  of  suppuration. 
Free  incision  and  drainage  would  in  all  probability  have  saved  the 
life  of  the  patient  to  whom  allusion  has  been  made.  In  all  cases 
of  acute  prostatic  inflammation  it  is  the  duty  of  the  surgeon  to  be  on 
the  alert  for  symptoms  of  suppuration.    Oftentimes,  however,  a  diag- 


ACUTE   PROSTATITIS.  363 

nosis  can  only  be  made  after  tlie  discharge  of  the  contained  pus  into 
the  urethra,  bladder,  or  rectum. 

Healing  of  prostatic  abscess  after  such  evacuation  is  often  quite 
prompt,  but  in  many  cases  the  admixture  of  urine  with  the  contents 
of  the  abscess  causes  serious  trouble  by  subsequent  decomposition 
and  septic  absorption. 

Ano-rectal  fistula  may  result  in  cases  in  which  the  abscess  opens 
or  is  evacuated  by  the  knife  through  the  rectum.  Urinary  fistula 
communicating  with  the  rectum  or  with  the  ano-rectal  fistula  may 
also  develop.  Urinary  fistula  following  evacuation  of  the  pus  through 
the  perineum  is  not  infrequent. 

MoKBiD  Anatomy. 

Comparatively  little  is  known  of  the  early  stages  of  acute  prostatic 
inflammation,  especially  of  the  follicular  or  parenchymatous  form. 
The  condition  is  not  a  fatal  one  and  the  opportunities  for  observation 
are  consequently  not  numerous.  As  far  as  determined,  however,  the 
process  appears  to  be  at  first  limited  chiefly  to  the  mucous  membrane, 
the  follicles,  and  the  glands  immediately  tributary  to  the  prostatic 
urethra ;  hence  a  description  of  the  morbid  anatomy  of  acute  follicular 
prostatitis  is  also  that  of  acute  posterior  urethritis.  In  the  follicular 
form  there  is  always  a  varying  degree  of  involvement  of  the  interstitial 
tissue,  largely  clependent  upon  the  duration  of  the  disease.  It  is  the 
author's  opinion  that  the  infectious  inflammation  never  limits  itself 
to  the  prostatic  urethra  alone ;  if  the  inflammation  does  not  extend 
below  the  membranous  tirethra,  it  may  possibly  become  limited  if  it 
be  not  too  acute  in  character.  In  acute  bulbo-membranous  inflam- 
mation, however,  the  prostatic  urethra  is  almost  inevitably  involved 
sooner  or  later.  The  mucous  membrane  of  the  prostate  is  reddened 
and  thickened,  as  is  true  of  the  mucous  membranes  in  all  situations 
under  the  influence  of  inflammation.  There  is  almost  invariably 
some  thickening  of  the  tissues  surrounding  the  lymphatics  and  blood- 
vessels. 

Ulceration  does  not  occur,  and  resulting  stricture  is  so  exceedingly 
rare  that  it  is  hardly  to  be  taken  into  consideration.  The  mouths  of 
the  prostatic  and  ejaculatory  ducts  are  involved  in  the  inflammation, 
thus  serving  to  explain  the  facility  with  which  the  inflammation  ex- 
tends to  the  glandular  tissues  of  the  organ.  In  acute  parenchymatous 
or  follicular  prostatitis  the  organ  is  swollen  according  to  the  degree 
of  circulatory  disturbance  and  peri-glandular  swelling. 

If  the  process  extends  to  the  inter-glandular,  muscular,  and  peri- 
prostatic tissues  we  have  the  difl'use  form  of  inflammation  as  accepted 


364  LYDSTON — DISEASES  OF  THE  PROSTATE. 

by  the  writer;  corresponding  to  tlie  parenchymatous  form  de- 
scribed by  Thompson.  The  organ  is  swollen  in  some  cases  to  three 
or  four  times  its  natural  size.  The  veins  of  the  prostatic  plexus  are 
distended  by  dark  blood.  The  arterial  vascular  supply  is  also  en- 
gorged. The  mucous  membrane  of  the  prostate  is  of  a  darker  red 
than  usual.  Pressure  causes  the  exudation  of  a  cloudy,  reddish  fluid 
containing  blood  from  the  engorged  capillaries  and  venules,  inflamma- 
tory lymj)h,  and  fluid  from  the  prostatic  glands,  with  a  small  quantity 
of  pus.  Brissaud  and  Segond  give  a  very  clear  description  of  the 
pathological  anatomy  of  acute  diffuse  prostatitis,  as  observed  in  a  man 
who  died  from  a  complicating  pleuro-pneumonia.  The  glandular 
tubes  were  the  seat  of  inflammation  of  a  degree  of  intensity  which 
was  variable  at  dift'erent  points.  The  internal  wall  of  the  ducts  at 
points  where  the  inflammation  was  most  intense  appeared  to  be 
blended  with  the  muscular  tissue  by  areas  of  inflammatory  exudate. 
The  inequality  of  the  inflammatory  process  was  especially  noticeable. 
In  different  places,  notably  at  the  iieriphery  of  the  organ,  marked 
pathological  changes  in  some  of  the  glandular  tissues  coexisted  with 
a  perfectly  healthy  condition  of  neighboring  glands  and  ducts.  The 
epithelium  lining  the  glandular  culs-de-sac  and  ducts  was  replaced  by 
an  agglomeration  of  new  tissue  elements,  often  filling  the  ampullae  of 
the  glands  completely'.  In  some  instances  the  degenerative  changes 
had  obliterated  the  normal  glandular  outlines. 

Suppuration  presents  itself  under  several  forms.  In  the  follicular 
form  the  suppuration  is  similar  to  that  which  occurs  in  gonorrhoea 
or  urethritis,  the  pathological  condition  from  which  the  process  in 
the  prostate  was  originally  derived.  Circumscribed  abscess  may 
form  in  the  follicular  form  of  acute  prostatitis.  One  or  more  glands 
become  infected,  and  incidentally  their  ducts  are  involved.  Occlu- 
sion of  the  lumen  of  the  latter  may  occur,  as  a  consequence  of  which  a 
suppurating  cyst-like  accumulation  of  pus  results.  One  or  more  of 
these  purulent  accumulations  may  rupture  and  contaminate  the  re-' 
mainder  of  the  gland.  Such  abscesses  are  often  responsible  for  re- 
current infection.  Miliar}^  abscesses  may  result  from  acute  suppura- 
tion. They  are  single  or  multiple  and  more  or  less  disseminated. 
Large  abscesses  may  be  found  in  some  cases.  Abscess  may  occur  in 
the  cellular  tissue  surrounding  the  prostate— peri-prostatic  abscess. 
Some  prostatic  abscesses  are  very  large.  Guyon  exhibited  a  speci- 
men in  which  the  urethra  was  completely  dissected  out  of  the  pros- 
tate and  was  entirely  surrounded  by  pus.  Abscess  cavities  are  gen- 
erally multilocular  and  trabeculated.  These  abscesses  may  open 
into  the  urethra  by  one  or  numerous  openings. 

Lallemand   many  years  ago  called  attention  to  the   fact  that  in 


ACUTE  PEOSTATITIS.  365 

acute  prostatitis  the  ejaculatory  ducts  may  be  dilated  and  thickened 
from  involvement  of  the  mucous  membrane.  They  may  be  ulcerated 
or  their  lumen  diminished,  or  in  extreme  cases  even  occluded.  The 
seminal  vesicles  may  be  thickened,  dilated,  and  contain  reddish  or 
puro-sanguinolent  fluid.  Regarding  the  accuracy  of  Lallemand's  ob- 
servations, a  certain  element  of  doubt  is  warrantable,  because  a  large 
proportion  of  his  patients  were  subjected  to  treatment  by  the  porte 
caustique,  which  in  itself  was  not  only  likely  to  set  up  acute  prostati- 
tis, but  was  very  likely  to  be  followed  by  occlusion  of  the  ejaculatory 
ducts. 

In  some  cases  of  suppuration  the  entire  glandulo-muscular  struc- 
ture of  the  prostate  is  destroyed,  as  in  the  case  outlined  by  Guyon. 
A  case  of  this  kind  came  under  the  observation  of  the  author.  The 
prostate  was  practically  replaced  by  a  suppurating  cavity  with  quite 
thick  walls,  representing  apparently  the  capsule  of  the  prostate  in 
conjunction  with  inflammatory  new  growth.  The  specimen  was  so 
damaged  in  removal,  however,  that  it  was  impossible  to  obtain  a  clear 
idea  of  the  relation  of  the  urethra  to  the  abscess. 

Symptoms. 

In  the  follicular  form  of  acute  prostatitis  the  symptoms  are  mainly 
subjective.  Frequent  and  painful  urination,  pain  being  especially 
marked  at  the  termination  of  the  act,  and  in  some  cases  the  escape 
of  a  certain  amount  of  blood  with  the  last  few  drops  of  urine  consti- 
tute the  principal  local  symptoms.  A  feeling  of  distress  in  the  peri- 
neum with  pain  radiating  along  the  urethra  into  the  spermatic  cords 
or  down  the  inner  aspect  of  the  thighs,  is  frequently  experienced. 
In  some  cases  there  is  more  or  less  pain  and  tenesmus  referable  to 
the  rectum.  The  stools  are  likely  to  be  somewhat  painful.  There 
may  be  considerable  constitutional  disturbance,  but  as  a  rule  this  is 
very  slight,  if  present  at  all,  excepting  where  there  is  a  greater  or 
less  degree  of  diffuse  inflammation.  In  the  diffuse  form  of  inflam- 
mation and  in  the  varieties  in  which  pus  formation  occurs,  there  is 
more  or  less  obstruction  to  the  flow  of  urine.  Complete  retention 
may  come  on  and  persist  until  such  time  as  the  abscess  evacuates 
itself  or  has  been  opened,  when  speedy  relief  of  the  symptoms  occurs. 
When  pathogenic  infection  of  the  prostate  occurs  independently  of 
preceding  follicular  inflammation,  there  may  be  comparatively  little 
irritation  about  the  vesical  neck,  the  symptoms  of  urinary  obstruction 
prexKjnderating.  This  is  especially  apt  to  be  the  case  in  those  acute 
forms  of  abscess  which  come  on  in  the  course  of  prostatic  hyper- 
trophy.   In  the  diffuse  and  supjjurative  forms  of  prostatitis,  the  pain 


366  LYDSTON — DISEASES  OF  THE  PKOSTATE. 

and  constitutional  symptoms  are  especially  marked.  Profound  de- 
pression is  likely  to  be  present,  and  in  prostatiques  especially  the 
patient  may  sink  into  a  typhoid  state  and  die  with  all  of  the  symp- 
toms of  constitutional  pyogenic  infection.  True  pyaemia  may  result 
as  a  consequence  of  a  localized  suppuration.  The  formation  of  pus 
is  likely  to  be  heralded  by  a  distinct  chill.  In  some  cases  a  succes- 
sion of  chills  may  occur.  In  some  cases  of  acute  prostatitis  the  dis- 
ease develops  very  suddenly.  In  some  instances  a  few  hours,  or  pos- 
sibly several  days,  may  elapse  before  the  symptoms  become  prominent. 
During  this  period  the  patient  experiences  premonitory  sensations  of 
weight  and  fulness  in  the  perineum,  with  frequent  micturition  and  a 
certain  degree  of  depression  incidental  to  the  irritation  of  the  vesical 
neck.  In  cases  in  which  abscess  forms  severe  throbbing  pain  is 
likely  to  come  on.  This  may  be  of  a  lancinating  rather  than  of  a 
throbbing  character,  radiating,  as  already  stated,  into  the  urethra, 
groins,  and  thighs.  The  slightest  exercise  tends  to  aggravate  the 
symptoms.  The  patient  very  often  finds  quite  early  in  the  course  of 
the  disease  that  slight  perineal  pressure  gives  rise  to  considerable 
pain  and  tenderness,  and  possibly  vesical  irritability. 

According  to  Thompson,  cystitis  is  likely  to  coexist  with  acute 
prostatitis,  but  in  the  opinion  of  the  author  this  is  quite  rare,  all  of 
the  symptoms  being  explicable  by  the  involvement  of  the  prostatic 
urethra.  In  cases  having  their  point  of  departure  in  follicular  inflam- 
mation, the  urine  contains  muco-pus  derived  from  two  sources :  First, 
that  which  is  directly  washed  out  of  the  prostatic  urethra  by  the  out- 
flowing urine ;  Second,  that  which  has  taken  the  direction  of  least  re- 
sistance and  escaped  back  into  the  bladder  during  the  intervals  of 
micturition.  The  first  and  last  portions  of  the  urine  in  cases  of  fol- 
licular inflammation  are  likely  to  contain  considerable  muco-pus,  the 
mid-stream  of  urine  being  comparatively  clear.  In  cases  in  which 
there  is  no  follicular  inflammation,  the  condition  being  primarily  one 
of  diffuse  inflammation,  or  of  localized  inflammation  incidental  to 
infection  and  followed  by  supj)uration,  the  urine  contains  nothing 
characteristic  until  such  time  as  the  abscess  ruptures  into  the  urethra 
or  bladder.  In  these  cases  the  patient  experiences  a  sudden  feeling 
of  relief  in  the  perineum  and  ano-rectal  region,  the  urine  flows  with 
perhaps  its  usual  freedom,  or  at  least  much  more  easily  than  before 
the  rupture  of  the  abscess,  and  pus  suddenly  appears  in  the  urine. 
It  does  not  escape  from  the  urethra  during  the  intervals  of  micturition 
unless  secondary  infection  of  the  anterior  urethral  mucous  membrane 
occurs,  or  unless  the  point  of  rupture  is  located  anterior  to  the  bulbo- 
membranous  junction. 

The  objective  symptoms  of  acute  prostatitis  vary  with  the  degree 


ACUTE   PROSTATITIS.  367 

of  diffuse  inflammation.  Where  the  pathological  process  is  largely 
of  a  follicular  character,  as  in  a  certain  proportion  of  cases  of  so-called, 
posterior  urethritis,  local  examination  elicits  very  little  save  more  or 
less  tenderness  on  deep  perineal  pressure  and  on  manipulation  of  the 
membranous  and  prostatic  portions  of  the  urethra  per  rectum.  Deep 
pressure  behind  the  pubes  may  elicit  a  certain  degree  of  tenderness 
referable  to  the  vesical  neck.  In  the  more  severe  types  of  diffuse 
and  circumscribed  suppurative  inflammation  more  or  less  heat,  swel- 
ling, tension,  and  tenderness  of  the  perineum  are  noticeable.  The 
prostate  presents  itself  as  a  hot,  tender  tumor  projecting  into  the  rec- 
tum antero-posteriorly.  The  degree  of  enlargement  varies  with  the 
extent  of  interstitial  inflammation,  and  may  be  so  marked  that  {he  fin- 
ger cannot  be  introduced  into  the  rectum  without  considerable  diffi- 
culty and  the  production  of  very  severe  pain.  When  suppuration  has 
occurred  a  boggy,  oedematous,  uniform,  or  circumscribed  bulging  of 
the  prostate  and  peri-prostatic  tissues  into  the  rectum  is  noticeable. 

Diagnosis. 

Although  the  main  diagnostic  points  in  acute  prostatitis  are  out- 
lined in  the  foregoing  symptomatology,  a  diagnostic  resume  and  con- 
sideration of  certain  special  points  in  the  differential  diagnosis  would 
seem  necessary.  The  patient,  generally  the  subject  of  acute  or  chronic 
urethritis,  complains  for  several  days  of  heaviness  and  pain  in  the 
perineum  which  he  is  quite  likely  to  attribute  to  fatigue  or  over-exer- 
tion, or  possibly,  if  he  be  one  of  the  exceptionally  honest  patients 
whom  we  sometimes  meet,  to  sexual  stimulation  or  indulgence.  In 
some  cases  the  patient  complains  for  several  days  of  loss  of  appe- 
tite, possibly  slight  chilliness  and  well-marked  malaise.  Considerable 
mental  depression  may  exist  for  some  time  before  definite  symptoms 
referable  to  the  perineum  occur.  Vesical  and  anal  tenesmus  with 
dysuria,  and  in  the  majority  of  cases  painful  and  difficult  defsecation, 
soon  develop.  In  other  instances,  the  first  indications  of  impending 
prostatic  inflammation  consist  in  symptoms  of  vesical  irritation.  In 
still  another  class  of  cases,  the  first  and  most  prominent  symptom 
consists  not  in  vesical  irritability,  but  in  urinary  obstruction,  which 
grows  more  and  more  prominent  and  is  apt  to  lead  to  complete  reten- 
tion. It  is  obvious  that  the  symptoms  are  governed  largely  by  the 
amount  of  inflammation  of  the  prostatic  urethra. 

In  cases  in  which  inflammation  of  the  posterior  urethra  is  not  the 
point  of  dei^arture,  as  is  true  in  many  cases  of  suppurative  inflamma- 
tion, there  may  be  little  or  no  vesical  irritation  throughout  the  course 
of  the  case.     Digital  exi)loration  of  the  rectum  and  perineum  shows 


368  LYDSTON — DISEASES   OF  THE  PKOSTATE. 

perineal  fulness  and  tenderness  and  a  degree  of  bulging  of  the  pros- 
tate into  tlie  rectum,  due  to  enlargement  of  tlie  organ,  proportionate 
to  tlie  severity  of  tlie  inflammation  and  the  degree  to  which  the  inter- 
stitial and  peri-prostatic  tissues  are  involved. 

Cowperitis  may  be  mistaken  for  inflammation  of  the  prostate. 
Palpation  of  the  perineum,  however,  shows  a  lateral  swelling  and,  if 
examined  early,  a  distinctly  circumscribed  spherical  tumor.  The 
prostate  on  rectal  examination  is  found  to  be  either  normal  or  only 
moderately  enlarged.  The  urinary  symptoms  may  be  nil.  The  pos- 
sibility of  follicular  prostatitis,  without  any  great  degree  of  enlarge- 
ment of  the  prostate,  existing  as  a  complication  of  Cowperitis,  or  vice 
versa,  should  be  taken  into  consideration. 

Cases  of  acute  inflammation  of  the  prostate  complicated  by  reten- 
tion may  require  differentiation  from  stricture,  especially  that  variety 
of  the  latter  in  which  retention  comes  on  suddenly  from  hypersemia 
and  spasm.  The  history  of  the  case,  digital  exploration  of  the  rec- 
tum, and  the  location  of  the  obstruction  generally  serve  for  differen- 
tiation. It  must  be  remembered,  however,  that  stricture  of  the  ure- 
thra is  quite  likely  to  be  complicated  by  prostatic  inflammation. 
Many  cases  of  genito-urinary  disease  of  an  acute  character  are  likely 
to  present  features  which  are,  to  say  the  least,  decidedly  mixed.  En- 
largement of  the  prostate,  as  a  cause  of  retention,  may  usually  be 
differentiated  from  acute  prostatitis,  by  the  age  and  history  of  the 
patient  and  the  peculiar  feel  imparted  to  the  finger  in  digital  explora- 
tion of  the  rectum..  The  tenderness  elicited  by  the  latter  method  of 
examination  may  be  very  slight  in  prostatic  hypertrophy.  The  pos- 
sibilitj^  of  acute  prostatitis  with  suppuration  or  the  formation  of  a 
chronic  abscess  as  a  complication  of  prostatic  hypertrophy  is  to  be 
borne  in  mind. 

Acute  cystitis  naaj  be  mistaken  for  inflammation  of  the  prostate. 
It  is  probable  that  by  far  the  majoritj^  of  cases  of  so-called  acute 
gonorrhoeal  cystitis  are  really  instances  of  acute  follicular  prostatitis. 
The  vesical  mucosa  proper  is  rarely  involved  in  gonorrhoeal  inflam- 
mation ;  indeed,  it  is  claimed  by  excellent  authorities  that  the  vesical 
mucosa  is  immune  to  the  gonococcus.  Be  this  as  it  may,  gonorrhoea 
is  a  mixed  infection  and  the  vesical  mucosa  may  become  infected  by 
germs  other  than  the  gonococcus.  It  is  not,  however,  particularly 
susceptible  to  simple  pus  infection. 

When  abscess  of  the  prostate  is  definitely  formed,  the  diagnosis 
is  generally  easy  unless  the  collection  of  pus  be  quite  small.  Espe- 
cially is  the  diagnosis  easy  when  the  abscess  points  toward  the  rec- 
tum. In  many  cases,  however,  the  diagnosis  is  not  only  difficult,  but 
the  abscess  is  not  detected  until  the  pus  has  escaped  by  the  urethra. 


ACUTE  PROSTATITIS.  369 

The  author  has  observed  a  number  of  cases  in  which,  although  pros- 
tatic abscess  W9^  strongly  suspected,  the  symptoms  were  of  rather 
moderate  intensity,  no  incision  was  made,  and  the  diagnosis  was  only 
cleared  up  by  the  sudden  escape  of  a  greater  or  less  quantity  of  pus 
from  the  urethra. 

Zeissl  calls  attention  to  the  possibility  of  confusion  of  prostatic 
with  ischio-rectal  abscess.  In  the  latter,  however,  there  are  no  es- 
pecial symptoms  referable  to  the  bladder  as  a  rule,  and  the  unilat- 
eral position  of  the  tumor  with  its  distinct  point  of  departure  in  the 
ischio-rectal  fossa  serves  to  clear  up  the  diagnosis.  In  some  instances 
ischio-rectal  abscess  is  associated  with  more  or  less  reflex  irritation 
of  the  vesical  neck.  This  may  prove  a  source  of  confusion.  The 
author  has  observed  one  case  in  which  ischio-rectal  abscess  occurred 
coincidentally  with  acute  follicular  prostatitis.  The  possibility  of  the 
coexistence  of  the  two  conditions  is  to  be  borne  in  mind.  In  prosta- 
titic  phlegmon,  and  in  all  forms  of  well-marked  prostatic  inflamma- 
tion, especially  where  suppuration  occurs,  the  gravity  of  the  consti- 
tutional symptoms  and  the  profound  nervous  depression  which  exists 
are  valuable  points  for  consideration  in  the  differential  diagnosis. 

Peognosis. 

The  prognosis  of  acute  prostatitis  in  otherwise  healthy  subjects  is 
quite  favorable  as  regards  the  immediate  recovery  of  the  patient, 
whether  suppuration  occurs  or  not.  As  already  indicated,  some  cases 
of  suppuration  prove  fatal,  this  being  especially  true  of  the  phlegmon- 
ous form  which  occurs  sometimes  in  young  subjects,  but  more  often 
in  prostatiques  in  whom  general  debility  is  more  marked  on  the  aver- 
age than  in  younger  men.  The  local  symptoms  are,  however,  likely 
to  be  improved  in  this  class  of  cases  after  the  evacuation  of  the 
abscess. 

According  to  Segond  the  prognosis  of  generalized  prostatic  phleg- 
mon is  rather  grave.  In  114  cases  collected  by  this  authority,  there 
were  34  deaths,  ten  cases  in  which  permanent  fistula  followed,  and  70 
recoveries.  Segond's  statistics  are  not  a  fair  criterion  of  the  gravity  of 
prostatic  abscess  taken  as  a  whole.  In  many  cases,  even  of  prostatic 
phlegmon,  an  incorrect  diagnosis  is  made,  yet  the  patient  eventually 
recovers  after  spontaneous  evacuation  of  the  pus.  In  the  milder  cases 
of  prostatic  abscess  pus  very  frequently  discharges  into  the  urethra 
and  apparent  cure  results,  the  true  condition  of  affairs  being  unrecog- 
nized. It  is  the  opinion  of  the  author  that  many  cases  in  which  sub- 
sidence of  the  prostatic  symptoms  is  coincidental  with  a  sudden  and 

marked  recurrence  of  the  urethral  discharge,  come  under  this  head. 
Vol.  I.— 24 


370  LYDSTON — DISEASES   OP  THE  PEOSTATE. 

In  both  young  and  old  subjects  witli  prostatic  abscess,  persistent 
pyuria  with  exacerbations  of  cystitis  and  urethritis  may  supervene. 
The  abscess,  after  evacuation  into  the  urinary  tract,  instead  of  closing 
down  and  becoming  obliterated,  remains  as  a  suppurating  sac  with 
one  or  more  openings  into  the  urinary  canal.  Decomposing  urine 
and  products  of  suppurative  inflammation  may  perpetuate  this  con- 
dition of  affairs  indefinitely.  In  most  cases  in  which  abscess  forms 
without  marked  follicular  inflammation,  the  patient  recovers  com- 
pletely. In  the  follicular  form  of  the  disease,  however,  and  in  those 
diffuse  and  suppurative  forms  in  which  follicular  inflammation  is  the 
primary  condition,  the  case  is  apt  to  become  very  stubborn.  In  the 
opinion  of  the  author,  no  patient  who  had  ever  suffered  from  acute 
follicular  prostatitis  ever  recovers  completely.  The  proportion  of 
patients  who  have  chronic  inflammation  of  the  prostate,  as  a  conse- 
quence of  acute  follicular  prostatitis  of  gonorrhoeal  origin,  is  much 
greater  than  is  ordinarily  beHeved.  Cases  taken  at  random  and 
studied  upon  the  post-mortem  table  in  our  large  cities  will  substan- 
tiate the  accuracy  of  this  assertion.  In  a  careful  study  of  nearly  two 
hundred  prostates,  taken  in  this  way,  the  writer  found  by  far  the 
larger  proportion  of  cases  to  present  evidences  of  more  or  less  recent 
inflammation,  in  which,  in  all  probability,  the  primary  condition  had 
been  one  of  acute  follicular  prostatic  inflammation.  Practical  obser- 
vation should  convince  any  thinking  man  that  a  prostate,  the  glandu- 
lar tissue  of  which  is  once  infected,  is  likely  to  be  always  more 
or  less  diseased. 

Teeatment. 

The  treatment  of  acute  prostatitis  should  be  very  active.  A  brisk 
mercurial  purge  should  be  ordered  at  once,  and  be  followed  by  a  full 
dose  of  some  saline  in  the  course  of  three  or  four  hours.  Ten  to 
fifteen  grains  of  calomel  followed  by  half  an  ounce  of  epsom  salts  is 
as  good  as  it  is  old-fashioned,  and  will  unload  the  portal  circulation, 
as  well  as  produce  general  depletion.  An  excellent  way  to  use  the 
mercurial  and  saline  treatment  is  to  put  the  patient  on  small  doses  of 
calomel,  giving  one-fifth  of  a  grain  in  tablet  triturate  form  every  three 
hours  until  four  or  five  doses  have  been  taken.  Coincidentally  with 
the  administration  of  the  calomel,  four-ounce  doses  of  a  saturated 
solution  of  sulphate  of  magnesia,  containing  glycerin  in  the  propor- 
tion of  about  1-3,  should  be  given  by  enema.  This  may  be  repeated 
till  the  patient  has  had  a  number  of  watery  evacuations.  This  is  the 
ideal  method  of  producing  pelvic  depletion,  and  is  quite  as  valuable 
in  prostatic  disease  as  in  pelvic  and  abdominal  inflammation  in  the 
female.     Having  fulfilled  this  indication,  there  are  several  special 


ACUTE  PEOSTATITIS.  371 

measures  which  are  essential.  The  febrile  symptoms  call  for  aconite 
or  veratrum  viride,  remedies  which  are  far  more  reliable  than  anti- 
mony, as  recommended  by  Thompson.  Ergot  and  the  fluid  extract 
of  hamamelis  are  probably  beneficial.  In  my  hands,  at  least,  they 
have  seemed  to  be  efficacious.  They  are  certainly  philosophical 
remedies  from  a  theoretical  standpoint.  These  remedies  may  advan- 
tageously be  combined  with  gelsemium  and  the  bromide  of  potas- 
sium; anaphrodisiac  remedies  having  an  especially  sedative  effect 
upon  the  inflamed  organ.  Hypodermic  injections  of  pilocarpine  have 
proved  serviceable  in  several  of  my  own  cases,  this  remedy  being  a 
powerful  derivative. 

After  the  bowels  have  been  evacuated  as  already  suggested,  opium 
is  the  remedy  upon  which  the  most  reliance  is  to  be  placed.  As  in 
all  inflammations,  opium  is  directly  antagonistic  to  inflammation  of 
the  prostate.  It  relieves  pain  and  strangury,  lessens  the  frequency 
of  micturition,  and  counteracts  nervous  depression.  Opium  and  other 
anodynes  act  best  in  acute  prostatitis  when  given  by  suppository. 
If  the  rectum  be  particularly  irritable,  the  anodyne  may  be  adminis- 
tered in  the  form  of  a  thin  ointment  to  be  injected  into  the  rectum. 
Iodoform  may  be  combined  with  morphine  and  belladonna  or  hyos- 
cyamus,  and  administered  in  the  form  of  a  suppository.  Care  should 
be  taken  to  avoid  large  doses  of  anodynes  per  rectum,  as  most  pa- 
tients are  much  more  susceptible  to  their  toxic  influence  when  given 
in  this  manner  than  is  usually  supposed.  If  the  administration  of 
anodynes  per  os  be  considered  preferable  to  rectal  medication,  codeine 
will  be  found  to  be  quite  as  reliable  and  much  less  disagreeble  than 
the  other  preparations  of  opium. 

The  diet  should  be  restricted  to  milk  or  other  unstimulating  fluid 
aliment,  and  the  patient  should  Ke  quietly  upon  his  back  "with  the 
hips  slightly  elevated.  Above  all  things,  the  patient  should  be  im- 
pressed with  the  absolute  necessity  of  perfect  rest  for  some  weeks, 
for  in  no  disease  is  movement  more  likely  to  aggravate  the  morbid 
condition  than  in  prostatitis.  In  many  cases  in  which  acute  prosta- 
titis assumes  a  subacute  or  chronic  form  and  persists  indefinitely, 
movement,  sexual  excitement,  alcoholic  and  dietetic  indulgence,  one 
or  all,  are  likely  to  be  in  great  measure  responsible.  Too  much 
stress  cannot  be  put  upon  the  necessity  of  perseverance  in  the  rules 
of  genito-urinary  hygiene. 

Local  depletion  should  be  resorted  to  early  in  the  case  and  re- 
peated from  time  to  time  as  circumstances  may  require.  This  is 
best  accomplished  by  means  of  leeches,  cups  being  rather  unhandy 
of  application.  Five  to  eight  leeches  should  be  applied  to  the  peri- 
neum and  about  the  anus,  and  the  bleeding  encouraged  by  warm 


372  LYDSTON — DISEASES  OF  THE  PROSTATE. 

fomentations.  The  rationale  of  this  treatment  is  obvious,  if  the  inti- 
mate association  of  the  prostatic  and  inferior  hemorrhoidal  plexuses 
be  taken  into  consideration.  After  the  hemorrhage  has  ceased,  hot 
poultices  or  fomentations  may  be  applied  to  the  perineum.  So 
great  is  the  relief  to  be  obtained  by  judicious  leeching  of  the  ano- 
perineal  region  in  acute  inflammation  of  the  prostate,  that  the  san- 
guinary enthusiasm  of  our  medical  forefathers  is  hardly  to  be  won- 
dered at.  It  is  perhaps  unfortunate  that  this  old-fashioned  method 
of  treatment  is  not  more  frequently  adopted,  not  only  in  acute  pros- 
tatitis but  in  other  diseases  in  which  local  depletion  is  a  desider- 
atum. 

Ice  has  been  advocated,  some  surgeons  even  advising  that  sup- 
positories of  ice  be  inserted  into  the  rectum.  Hot  water  containing 
laudanum  is  often  serviceable  as  an  enema.  Simple  hot  enemata, 
several  quarts  of  water  being  used  at  each  sitting,  may  be  given 
several  times  daily  with  great  advantage. 

Interference  with  the  urethra  should  be  avoided,  the  usual  treat- 
ment for  gonorrhoea — if  the  disease  exists — being  suspended  during 
the  course  of  the  prostatic  inflammation.  The  use  of  injections  may  de- 
termine the  formation  of  an  abscess  in  an  otherwise  slight  prostatitis. 

Hot  sitz-baths,  twice  or  thrice  daily,  are  of  marked  benefit  in 
prostatitis ;  in  order  to  be  beneficial,  however,  they  must  be  very  hot 
and  continued  for  at  least  an  hour.  Should  retention  occur  and 
opium  and  the  hot  sitz-baths  fail  to  relieve,  then,  and  then  only,  is 
catheterism  permissible.  A  small  soft  catheter  should  be  carefully 
introduced  and  the  urine  drawn  off.  Failing  in  this,  aspiration  may 
be  required.  Throughout  the  course  of  the  case,  rectal  examinations 
should  be  made  as  infrequently  as  possible.  This  precaution  is  by 
no  means  gratuitous,  for  the  average  surgeon  is  usually  over-anxious 
to  observe  the  progress  of  the  case,  and  in  his  misplaced  enthusiasm 
is  apt  to  do  injury.  As  the  acuteness  of  the  inflammation  becomes 
less  manifest,  counter-irritation  by  means  of  iodine  or  blisters  to  the 
perineum  may  prove  of  great  service.  Systematic  and  repeated  blis- 
tering may  perhaps  prevent  the  sujjervention  of  chronic  inflammation. 

Under  careful  treatment  the  inflamed  organ  will  begin  to  subside 
and  the  symptoms  will  improve  in  a  few  dajs,  but  it  will  be  several 
months  before  the  prostate  will  assume  anything  like  its  normal  size. 
The  slightest  excess  is  apt  to  cause  a  relapse,  and  the  patient  will 
ever  after  be  susceptible  to  fresh  attacks  of  inflammation — reinfec- 
tion— from  apparently  trivial  causes.  Very  insignificant  indiscre- 
tions are  liable  to  prevent  resolution  and  cause  the  inflammatory 
process  to  become  chronic.  Prostatitis  may  consequently  be  a  very 
unsatisfactory  affection  to  treat,  in  the  most  tractable  and  conscien- 


ACUTE  PROSTATITIS.  373 

tious  patients.  Eecurrent  infection  of  the  urethra  simulating  a  fresh 
gonorrhoea  is  one  of  the  most  annoying  features  of  the  disease. 

Abscess. — In  a  general  way  the  liability  to  prostatic  abscess  in  the 
course  of  acute  prostatitis  depends  upon  the  assiduity  with  which  the 
foregoing  measures  of  treatment  of  acute  inflammation  are  carried  out. 
In  cases  in  which  the  prostatic  inflammation  is  due  to  the  absorption 
of  pus  microbes  and  their  products  through  an  abrasion,  or  via  the 
lymphatics  without  abrasion,  with  resulting  infection  of  the  inter- 
stitial tissue  of  the  prostate,  suppuration  is  almost  inevitable.  In 
the  ordinary  diffuse  form  of  inflammation,  however,  and  in  the 
follicular  form  which  precedes  it,  energetic  and  conscientious 
treatment  may  avert  the  development  of  an  abscess.  The  treatment 
of  acute  abscess  of  the  prostate  is  obviously  that  of  acute  prostatitis. 
When  pus  has  formed  or  when  there  exists  a  strong  suspicion  of  its 
presence,  surgical  intervention  is  absolutely  indicated.  While  conser- 
vative treatment  by  means  of  poultices  to  the  perineum  and  the  injec- 
tion of  hot  water  into  the  rectum  may  be  justifiable  in  cases  in  which  the 
presence  of  pus  is  extremely  doubtful,  the  practitioner  should  beware 
of  carrying  conservatism  too  far.  Serious  results  may  accrue  from  a 
large  accumulation  of  pus  in  and  about  the  prostate  long  before  fluc- 
tuation is  manifest.  Fluctuation  should  be  carefully  sought  for,  it 
is  true,  but  in  by  far  the  majority  of  cases  operation  is  demanded 
long  before  a  sense  of  fluctuation  can  be  detected  in  the  perineum. 
In  cases  in  which  the  abscess  involves  the  periprostatic  tissue  or 
open^  toward  the  rectum,  digital  examination  of  the  gut  is  likely  to 
detect  either  well-marked  fluctuation  or  that  peculiar  oedematous  con- 
dition which  is  characteristic  of  the  presence  of  pus. 

As  soon  as  the  diagnosis  of  abscess  is  justified  by  the  develop- 
ment of  a  brawny  induration  and  swelling  of  the  perineum,  the  char- 
acteristic oedematous  condition,  or  distinct  fluctuation  on  rectal 
examination,  a  free  incision  in  the  direction  of  the  prostate  should 
'be  made  in  the  perineal  raphe.  This  locality  should  always  be 
selected  even  where  well-marked  fluctuation  on  rectal  examination 
indicates  the  presence  of  pus  in  the  periprostatic  tissue.  Tempted  by 
the  close  proximity  of  the  pus  and  the  ease  with  which  it  was  to  be 
reached  by  the  rectum,  the  author  has  on  several  occasions  operated 
through  the  rectal  wall  with  results  which  were  by  no  means  as  pleas- 
ant as  could  be  wished,  and  by  no  means  to  be  compared  with  those 
obtained  by  the  perineal  operation.  In  case  pus  should  not  be  found 
by  the  perineal  incision,  the  surgeon  can  console  himself  with  the 
reflection  that  he  has  adopted  the  best  possible  means  to  prevent  the 
formation  of  an  abscess,  and  in  case  suppuration  should  eventually 
occur  he  has  afforded  an  outlet  in  the  most  favorable  direction.     If 


374  LYDSTON — DISEASES  OF  THE  PROSTATE. 

several  foci  of  suppuration  be  found  thej  sliould  be  freely  opened 
and  drained.  Iodoform  gauze  drainage  sbould  be  adopted  after  evac- 
•uation  of  tlie  purulent  accumulation.  Infiltration  of  urine  may  pos- 
sibly occur  after  the  opening  of  an  abscess,  but  it  is  certainly  very 
rare. 

Wlien  a  prostatic  or  peri-prostatic  abscess  is  opened  from  tlie  rec- 
tum, or  discharges  spontaneously  into  the  gut,  extensive  infection 
with  the  formation  of  ischio-rectal  abscess  and  external  fistula  or  a 
permanent  internal  fistula  may  result.  In  all  cases  in  which  the 
abscess  has  been  evacuated  into  the  rectum,  careful  antiseptic  irriga- 
tion is  necessary.  Care  should  be  taken,  however,  to  avoid  poison- 
ing the  patient  by  too  strong  antiseptic  solutions.  Carbolic  acid  and 
the  bichloride  of  mercury  are  particularly  open  to  impeachment  on 
this  score.  A  saturated  solution  of  boric  acid  is  much  safer,  al- 
though necessarily  not  so  efiicient.  It  may  become  necessary  to 
divulse  the  sphincter  ani  to  relieve  rectal  tenesmus  or  secure  perfect 
drainage.  By  putting  the  sphincter  at  rest,  it  may  be  possible  to 
induce  healing  without  the  necessity  of  more  serious  operative  pro- 
cedures. In  the  event,  however,  that  a  permanent  fistula  results,  it 
should  be  dealt  with  as  in  ordinary  cases  of  ano-rectal  fistula. 
When  the  abscess  ruptures,  or  is  evacuated  by  the  perineal  route, 
there  is  danger  of  permanent  urinary  fistula.  When  the  pus  is 
evacuated  in  the  direction  of  the  urethra,  the  repeated  formation  of 
peri-urethral  abscesses  may  eventually  result  in  the  formation  of  a 
perineal  fistula.  When  the  pus  is  external  to  the  prostate  in  the 
para-prostatic  tissue,  there  is  less  danger  of  infiltration  of  urine  and 
urinarj^  fistula  than  in  cases  in  which  the  prostate  proi^er  is  involved. 

General  supportive  measures  and  possibly  the  administration  of 
stimulants  may  be  necessary  after  the  evacuation  of  a  prostatic 
abscess.  This  course  should  be  invariably  adopted  in  cases  of  pros- 
tatic abscess  im  prostatiques.  Should  pyaemia  occur  in  the  course  of 
prostatic  abscess,  it  is  likely  to  be  in  old  cachectic  and  debilitated  sub- 
jects, and  death  is  practically  inevitable.  In  cases  in  which  retention 
occurs  from  prostatic  inflammation  or  abscess,  especially  in  old  sub- 
jects, it  may  be  impossible  to  evacuate  the  urine  with  the  ordinary 
form  of  catheter.  The  catheter  coude  of  Mercier  may  be  introduced 
much  more  readily  than  the  ordinary  form  of  catheter.  A  soft  Nela- 
ton  catheter  is,  in  the  experience  of  the  author,  often  unsatisfactory. 
In  passing  the  elbowed  catheter  the  superior  urethral  wall  is  so 
closely  hugged  that  there  is  comparatively  little  danger  of  penetrating 
the  abscess  cavity  with  the  instrument.  Instances  have  been  known 
where  the  abscess  cavity  has  thus  been  penetrated  and  was  taken  for 
the  bladder.     The  important  fact  is  to  be  remembered  that  it  is  far 


CHRONIC  PROSTATITIS. 


375 


better  to  evacuate  an  abscess  by  an  external  incision  than  to  produce 
an  internal  opening  into  the  urethra  or  to  allow  such  an  opening  to 
occur  spontaneously.  It  is  admitted  that  in  many  cases  in  which 
the  abscess  opens  in  the  direction  of  the  urethra,  the  patient  recovers 
speedily  and  completely,  but  in  a  certain  proportion  of  cases  perma- 
nent infection  results  with  all  the  dangers  of  urethritis,  cystitis,  and 
recurrent  prostatic  abscesses. 

Chronic  Prostatitis. 

Considering  the  frequency  of  chronic  inflammation  of  the  prostate, 
it  is  rather  remarkable  that  it  was  practically  unrecognized  until  the 
early  part  of  the  present  century.  It  must  be  acknowledged,  more- 
over, that  considerable  confusion  on  this  subject  exists  in  the  minds 
of  clinical  observers  even  at  the  present  day. 

Yarieties. 

Chronic  prostatitis  presents  itself  under  three  forms,  namely : 

1.  The  follicular  or  parenchymatous,  involving  chiefly  the  glandu- 
lar tissues  of  the  organ ; 

2.  The  chronic  diffuse,  involving  the  lymphatics,  connective  and 
muscular  tissues  of  the  prostate  proper,  and  also  as  a  rule  the  tissues 
of  the  seminal  vesicles  and  vas  deferens,  and  the  para-prostatic 
tissue ; 

3.  The  chronic  suppurative. 


Etiology. 

The  causes  of  chronic  prostatitis  may  be  conveniently  grouped  in 
the  following  table : 

'  Masturbation. 

Sexual  desire  without  gratification. 

Sexual  excess. 

Passage  of  instruments. 

Urethral  or  bladder  disease. 

Prostatic  hypertrophy. 

Ano-rectal  disease. 

Constipation  with  consequent  strain- 
ing at  stool. 

Frequent      defa3cation   in    chronic 
diarrhoea  and  dysentery. 

Over-exertion. 

Bicycling  and  horseback  riding. 

Dietetic  and  alcoholic  excesses, 
t  Exposure  to  cold. 

Diatheses Gouty,  rheumatic,  or  tubercular. 


'  Hypersemia  due  to. 


Predisposing  causes 


J76  LYDSTON — DISEASES  OF  THE  PROSTATE. 

f  Acute  inflammation  from  any  cause,  usually  from  infection. 
Eepeated  traumatism  from  urethral  instrumentation,  or  ex- 
ternal blows. 
Infection  from  instrumentation. 

Gradual  extension  of  chronic  inflammation  from  the  urethra 
or  bladder. 
Exciting  causes.  ■  ■ .  -{  Infection  by  the  products  of  cystitis. 

Infection  by  pus  microbes  without  traumatism. 

Infection  by  the  baciUus  tuberculosis. 

Eepeated    over-stimulation    by    irritant  applications  to    the 

prostatic  urethra-. 
Over- stimulation  by  drugs  taken  internally,  as  cantharides, 
[      turpentine,  etc. 

It  is  hardly  necessary  to  expatiate  upon  the  role  of  liypersemia  in 
tlie  etiology  of  chronic  prostatis.  It  is  not  likely  that  any  of  the 
factors  enumerated  as  predisposing  causes  can  when  acting  alone  pro- 
duce chronic  prostatitis.  Several  of  them  taken  together  may,  how- 
ever, act  as  exciting  causes.  Thus  sexual  excess  and  alcoholism  in 
combination  with  the  gouty  or  rheumatic  diathesis,  particularly  if 
associated  with  exposure  to  cold,  may  produce  chronic  prostatitis.  It 
must  be  remembered,  however,  that  in  by  far  the  majority  of  cases 
in  which  these  factors  are  apparently  responsible  for  the  chronic  in- 
flammation, some  source  of  infection  or  of  direct  irritation  of  the^ 
prostate  exists.  The  more  carefully  these  cases  are  studied,  the 
more  essential  infection  appears  to  be  in  the  causation  of  chronic 
prostatitis,  this  being  especially  true  of  the  follicular  form.  It  is  not 
denied  that  cases  of  chronic  diffuse  prostatitis  are  met  with,  espe- 
cially in  middle-aged  men,  where  no  history  of  gonorrhoeal  or  instru- 
mental infection  can  be  elicited.  Careful  inquiry,  however,  determines 
some  source  of  infection  in  by  far  the  majority  of  cases.  The  possi- 
bility of  auto-infection  from  deep  urethral  catarrh,  brought  on  by  the 
numerous  predisposing  factors  which  have  been  outlined,  is  here  to  be 
taken  into  consideration.  Middle-aged  patients  who  present  them- 
selves with  symptoms  of  prostatic  disease,  and  in  whom  upon  exami- 
nation an  enlarged,  moderately  soft,  tender,  and  obviously  inflamed 
prostate  is  found,  are  usually  gouty  or  rheumatic,  are  high  livers, 
and  as  a  rule  acknowledge  sexual  excesses.  That  such  a  condition 
may  be  the  foundation  for  senile  hypertrophy  of  the  prostate  is  highly 
probable.  In  some  instances  the  development  of  chronic  inflamma- 
tion, pai-ticularlj^  of  the  interstitial  variety,  is  so  insidious  that  the 
patient's  attention  is  not  directed  to  his  condition  until  mafly  years 
after  the  inception  of  the  disease.  He  may  or  may  not  recall  a  gon- 
orrhoea occurring  during  his  years  of  indiscretion.  If  he  does  recall 
it,  it  is  generally  with  the  idea  that  he  was  perfectly  restored  to  health 
after  the  gonorrhoea,  when,  as  a  matter  of  fact,  the  foundation  for 
his  present  trouble  was  laid  at  that  time.     Cases  are  occasionally 


CHRONIC  PROSTATITIS.  377 

met  witli,  on  tlie  other  hand,  in  which  a  history  of  continuous  vesical 
irritation  is  related  and  referred  by  the  patient  to  his  old-time 
gonorrhoea. 

The  injudicious  passage  of  instruments  into  the  bladder  is  often- 
times responsible  for  chronic  prostatitis.  The  instrumentation  acts 
in  two  ways :  (1)  By  producing  mechanical  irritation  and  hyperemia ; 
(2)  by  carrying  infection  from  the  anterior  urethra  to  the  deeper 
parts  of  the  canal.  The  hypersemia  excited  by  the  frequent  instru- 
mentation supplies  the  necessary  susceptibility  to  germ  infection. 
The  microbes  and  their  products  conveyed  by  the  instruments  thus 
have  an  excellent  culture-bed  prepared  for  them.  Irritation  of  the 
lower  bowel  and  the  bruising  incidental  to  chronic  constipation  or 
frequent  defsecation  in  bowel  diseases  are  very  potent  factors  in  the 
production  of  chronic  prostatitis.  The  slightest  infection  or  expo- 
sure superadded  to  the  condition  of  irritation  and  hypersemia  already 
existing  is  likely  to  set  up  a  low  grade  of  inflammation  which  usually 
becomes  chronic.  The  same  may  be  stated  regarding  the  effects  of 
excessive  indulgence  in  bicycling  and  horseback  riding.  The  excit- 
ing causes  of  chronic  prostatitis  which  have  been  enumerated  are 
with  few  exceptions  effective  only  through  the  medium  of  infection. 
Even  in  the  case  of  repeated  overstimulation  of  the  prostatic  urethra 
by  irritant  drugs  infection  may  play  a  very  important  role,  secon- 
dary, it  is  true,  but  none  the  less  important.  Infection,  however,  in 
such  cases  is  probably  not  absolutely  necessary  to  the  production  of 
inflammation.  In  the  case  of  chronic  suppurative  prostatitis  it  is 
obvious  that  pus  microbes  play  the  most  important  part.  The  pyo- 
genic germs  may  enter  the  organ  by  way  of  its  ducts  and  glands  or 
by  lymphatic  absorption.  Lymphatic  absorption  is  generally  i)recipi- 
tated  by  traumatic  abrasion  of  some  portion  of  the  urethral  tract- 
most  generally  the  prostatic  portion.  It  may,  however,  in  all  proba- 
bility occur  through  the  unbroken  mucous  membrane.  That  it  may 
occur  by  way  of  the  general  circulation  is  shown  in  certain  cases  of 
variola  and  parotiditis.  In  such  cases  the  suppurative  process  is 
generally  an  acute  one,  yet  it  may  be  of  a  chronic  character  and  is 
very  likely  to  be  unrecognized  until  serious  damage  has  resulted. 
A  fatal  issue  without  special  symptoms  referable  to  the  prostate 
is  possible. 

Chronic  Follicular  or  Parenchymatous  Prostatitis. — The  nomen- 
clature of  this  variety  is  based  upon  the  same  proposition  which  was 
laid  down  in  the  consideration  of  acute  follicular  prostatitis,  namely, 
that  the  secreting  glandular  structures  of  the  prostate  and  their  ducts 
constitute  the  essential  anatomical  elements  of  the  organ  and  should 
therefore  be  regarded  as  the  true  parenchyma.     Chronic  parenchy- 


378  LYDSTON — DISEASES  OF  THE  PEOSTATE. 

matous  prostatitis  necessarily  involves  tlie  glandular  structures  of  the 
organ  and  usually  tlie  prostatic  urethra,  the  latter  being  the  point  of 
departure  of  the  inflammation  in  nearly,  if  not  quite,  all  cases.  The 
mucous  membrane  of  the  prostatic  urethra- may  regain  an  approxi- 
mately normal  condition,  while  the  glandular  inflammation  remains 
for  an  indefinite  period.  Chronic  follicular  or  parenchymatous  pros- 
tatitis embraces  a  variety  of  erroneously  diagnosed  affections.  Cysti- 
tis, urethral  stricture,  neuralgia  of  the  vesical  neck,  posterior  urethritis, 
prostatorrhoea,  spermatorrhoea,  and  catarrh  of  the  bladder  constitute 
some  of  the  diagnoses  under  which  chronic  follicular  prostatitis  is 
likely  to  masquerade.  The  disease  may  be  associated  with  a  certain 
amount  of  chronic  diffuse  inflammation;  indeed,  the  two  conditions 
are  quite  frequently  combined.  Many  cases  are  met  with  in  which 
the  glandular  inflammation  is  the  essential  condition,  the  interstitial 
involvement  being  a  subordinate  feature  and  apparently  secondary  to 
the  glandular  disturbance.  In  some  instances  chronic  parenchyma- 
tous prostatitis  has  been  preceded  by  well-marked  acute  parenchyma- 
tous inflammation  associated  with  diffuse  involvement  of  the  pros- 
tatic tissue,  yet  the  interstitial  inflammation  has  practically  subsided 
without  any  appreciable  improvement  in  the  glandular  inflammation. 
As  has  already  been  remarked  in  connection  with  acute  follicular 
prostatitis,  this  form  of  inflammation  of  the  prostate  has  a  greater 
tendency  toward  chronicity  than  the  interstitial  variety. 

Chronic  follicular  prostatitis  is  usually  due  to  infection  and  fol- 
lows as  a  rule  the  acute  form  of  inflammation.  In  by  far  the  larger 
proportion  of  cases  the  patient  gives  a  history  of  gonorrhoea  with 
some  complication  which  has  been  referred  to  the  deep  urethra, 
bladder,  or  prostate.  Broadly  speaking,  a  patient  who  does  not  give 
a  history  of  some  acute  disturbance  of  the  function  of  micturition 
during  the  course  of  a  gonorrhoea  is  not  very  likely  to  be  suffering 
from  this  form  of  prostatic  inflammation.  If,  however,  such  a  his- 
tory be  given  it  is  safe  to  infer  that  some  morbid  condition  of  the 
prostate  is  still  present.  The  exceptions  to  this  rule  the  author  be- 
lieves to  be  very  few.  In  some  few  instances,  perhaps,  the  deep 
urethra  becomes  infected  and  the  inflammatory  process  limits  itself 
to  the  membranous  portion  of  the  canal.  Such  cases,  however,  must 
certainly  be  the  exception.  In  by  far  the  larger  proportion  of  in- 
stances the  prostatic  urethra  and  almost  inevitably  the  glandular 
structures  of  the  prostate  become  involved  sooner  or  later  in  cases  in 
which  deep  infection  occurs.  Once  the  prostate  is  infected,  whether 
or  not  a  diffuse  inflammation  develops,  it  is  the  author's  firm  con- 
viction that  a  perfect  restoration  to  health  never  thereafter  occurs. 
The  frequency   of  chronic  inflammation  of  the  prostate  is   much 


CHEONIC  PROSTATITIS.  379 

greater  tlian  is  generally  believed,  as  may  be  demonstrated  by  a 
careful  dissection  of  a  number  of  prostates  taken  at  random,  espe- 
cially among  hospital  patients.  Wlien  we  consider  tlie  multitudinous 
glands  and  ramifications  of  ducts  which,  constitute  the  most  import- 
ant part  of  the  prostate  and  the  poor  facilities  for  drainage  afforded 
these  tissues,  the  prolonged  duration  of  infectious  processes  is  by  no 
means  remarkable. 

The  subjective  signs  of  the  inflammation  depend  largely  upon  the 
degree  and  duration  of  the  inflammation  of  the  prostatic  urethra.  The 
objective  signs  depend  mainly  on  the  degree  of  involvement  o^  the 
interstitial  tissue.  Careful  examination  may  fail  to  detect  any  alter- 
ation in  the  size,  consistency,  form  and  sensibility  of  the  prostate  even 
when  well-marked  chronic  follicular  inflammation  exists.  The  uri- 
nary symptoms  having  subsided  and  the  prostate  having  apparently 
returned  to  its  normal  condition,  as  far  as  rectal  examination  enables 
us  to  determine,  it  will  still  be  found  that  upon  the  slightest  indis- 
cretion or  exposure  the  patient  is  likely  to  have  attacks  of  vesical  irri- 
tation and  tenesmus  which  usually  pass  as  exacerbations  of  cystitis. 

Symptoms. 

Chronic  Parenchymatous  Prostatitis. — The  patient  usually  gives  a 
history  of  a  more  or  less  recent  attack  of  gonorrhoea  with  complicat- 
ing deep-seated  inflammation  which  has  been  referred  to  the  posterior 
urethra,  bladder,  or  prostate,  according  to  the  notion  of  the  physi- 
cian who  has  happened  to  have  the  case  in  hand.  There  is  often  a 
history  of  complicating  epididymitis  which  is  sometimes  in  itself  an 
evidence  of  prostato-urethral  inflammation.  The  symptoms  of  irri- 
tation of  the  vesical  neck  characteristic  of  follicular  or  parenchyma- 
tous prostatitis  may  have  subsided  and  the  patient  may  assert  that 
he  had  been  perfectly  well  for  some  little  time,  a  relapse  having  been 
brought  on  by  indiscretion  or  exposure  to  cold.  On  careful  ques- 
tioning, however,  it  will  be  found  that  slight  symptoms  referable  to 
the  neck  of  the  bladder  and  the  region  of  the  prostate,  consisting  of 
more  or  less  weight,  voluptuous  sensations  with  slight  increase  in  the 
frequency  of  micturition,  and  in  a  general  way  symptoms  of  hyperses- 
thesia  of  the  prostatic  urethra  have  persisted  since  the  original  acute 
attack  of  inflammation.  In  other  instances  the  patient  gives  a  his- 
tory of  continuous  vesical  irritation  of  greater  or  less  degree  of 
severity  since  the  primary  involvement  of  the  prostatic  urethra.  The 
principal  symi>toms  of  which  patients  complain  are  frequency  of  mic- 
turition, with  more  or  less  pain  and  perhaps  a  slight  (juantity  of 
blood  at  the  termination  of  the  act  as  the  deep  jjerineal  muscles  con- 


380  LYDSTON — DISEASES  OF  THE   PROSTATE. 

tract  upon  tlie  tender  prostate.  Tlie  urinary  symptoms  in  general 
are  not  unlike  those  of  vesical  calculus.  The  sexual  function  is  more 
or  less  disturbed.  Nocturnal  pollutions,  premature  and  perhaps 
painful  ejaculations  may  exist.  The  seminal  discharges  may  be 
mixed  with  a  greater  or  less  quantity  of  blood.  This  is  especially 
apt  to  be  the  case  if  the  seminal  vesicles  be  involved.  A  sensation  of 
fulness  perhaps  with  a  tinge  of  voluptuousness  in  the  perineum,  itch- 
ing and  tickling  sensations  in  the  perineum,  urethra,  anus,  and  rec- 
tum are  often  met  with.  The  'patient  may  be  annoyed  by  frequent 
and  persistent  erections,  and  excessive  sexual  desire  may  exist.  Pa- 
tients are  quite  likely  to  go  to  the  other  extreme  and  complain  of 
complete  loss  of  sexual  ai^petite  and  of  inability  to  perform  the  sexual 
act.  More  or  less  congestion  or  inflammation  of  the  anterior  urethra 
may  be  present,  as  a  consequence  either  of  simple  irritation  and  cir- 
culatory disturbance,  or  of  infection  from  the  deeper  portion  of  the 
canal;  as  a  result  there  is  more  or  less  oozing  of  muco-purulent 
discharge  from  the  meatus.  This  muco-purulent  discharge  is  more 
profuse  during  defaecation  and  at  the  end  of  micturition,  and  may  be 
noticeable  only  at  such  times.  It  is  to  be  distinctly  understood  that 
whenever  discharge  appears  from  the  meatus  during  the  intervals  of 
micturition  and  defsecation  some  morbid  condition  of  the  anterior  ure- 
thra necessarily  exists.  More  or  less  backache  with  neuralgic  pains 
along  the  spermatic  cord,  in  the  testes,  groins,  thighs,  and  radiating 
into  the  urethra  may  exist.  The  patient  is  quite  likely  to  complain 
of  a  pain  located  an  inch  or  so  behind  the  meatus  on  the  under  surface 
of  the  urethra.  This  pain  is  apt  to  be  misleading  both  to  the  patient 
and  practitioner,  and  is  very  similar  to  that  which  is  experienced  in 
vesical  calculus.  The  mind  of  the  patient  is  rarely  tranquil,  and  he 
is  usually  imbued  with  the  idea  that  he  has  spermatorrhoea,  as 
might  naturally  be  expected.  The  discharge  may  contain  spermato- 
zoa where  the  stool  is  difficult  and  much  pressure  is  brought  to  bear 
upon  the  seminal  vesicles.  As  a  rule,  however,  it  is  muco-purulent  in 
character  and  is  composed  of  pus,  mucus,  and  fatty  detritus  with  more 
or  less  epithelium.  Where  the  vesical  neck  is  profoundly  implicated, 
the  peculiar  ovoid  epithelium  characteristic  of  this  location  is  apt 
to  be  found. 

The  urine  contains  muco-pus  and  epithelium,  the  characters  vary- 
ing with  the  degree  of  posterior  urethritis  present.  The  so-called 
Tripperfaden  and  the  peculiar  horseshoe-nail-shaped  filaments  or 
flocculi  characteristic  of  inflammation  of  the  prostatic  follicles  are 
usually  found.  Exercise  increases  the  symptoms ;  there  is  more  or 
less  discomfort  attending  the  act  of  defsecation,  and  the  patient  is  very 
likely  to  apply  for  relief  for  rectal  and  anal  disease,  his  symptoms 


CHRONIC  PEOSTATITIS.  381 

being  almost  altogether  referable  to  this  region.  If,  as  may  be  the 
case,  the  prostatic  trouble  be  complicated  by  piles,  fissures,  or  fistula, 
an  erroneous  diagnosis  is  quite  likely  to  be  made ;  especially  is  there 
an  interdependence  between  the  condition  of  the  prostate  and  that  of 
the  ano-rectal  region.  The  writer  has  at  present  under  observation 
a  patient  who  states  that  there  is  a  very  peculiar  oscillation  in  his 
symptoms.  When  the  symptoms  referable  to  the  neck  of  the  bladder 
and  prostate  are  most  severe  there  is  less  discomfort  in  the  region  of 
the  rectum,  and  vice  versa. 

Chronic  Diffuse  Prostatitis. — As  has  already  been  asserted,  the 
parenchymatous  form  of  ihe  disease  is  apt  to  be  associated  with  a 
greater  or  less  degree  of  diffuse  inflammation.  The  severity  of  the 
symptoms  is  in  direct  proportion  to  the  degree  of  diffuse  inflamma- 
tion present  in  cases  in  which  the  two  conditions  are  associated.  The 
symptoms  of  the  diffuse  form  are  obviously  essentially  the  same  as 
those  already  outlined,  with,  however,  certain  exceptions,  due  to  a 
difference  in  the  etiology  of  the  case.  In  cases  in  which  the  glandu- 
lar inflammation  follows  acute  infection,  which  usually  occurs  in 
comparatively  young  subjects,  the  principal  condition  present  is  one 
of  chronic  inflammation  of  the  glands  and  ducts  of  the  prostate,  and 
the  symptoms  referable  to  the  urinary  and  sexual  functions  are  more 
marked  than  in  those  cases  occurring  in  middle-aged  men  in  whom 
the  gouty  or  rheumatic  diathesis,  high  living,  excesses,  and  a  com- 
paratively mild  degree  of  infection  are  responsible  for  the  condition 
present.  In  such  patients  the  urinary  symptoms  may  be  compara- 
tively mild  until  such  time  as  mechanical  disturbance  of  the  function 
of  micturition  supervenes.  In  these  cases,  too,  the  discharge  may  not 
be  present,  although  the  urine  may  give  evidence  of  a  chronic  inflam- 
mation of  the  prostatic  urethra  of  low  grade.  In  some  instances  there 
is  not  only  no  discharge  but  the  urine  is  absolutely  normal.  While 
in  the  parenchymatous  form  of  the  disease  there  may  be  little  or  no 
enlargement  of  the  prostate,  in  the  variety  at  present  under  considera- 
tion the  prostate  is  distinctly  and  sometimes  considerably  enlarged. 
In  both  forms  of  the  disease  there  is  more  or  less  tenderness  upon 
pressure  in  the  perineum,  and  decided  tenderness  with  an  urgent  desire 
to  micturate  on  digital  pressure  through  the  rectum.  The  psychic 
disturbance  in  middle-aged  subjects  with  diffuse  chronic  inflamma- 
tion of  the  prostate  is  either  subordinate  or  entirely  absent.  Aberra- 
tions of  the  sexual  function,  however,  are  frequently  met  with,  although 
they  are  not  likely  to  be  regarded  by  the  patient  with  the  degree  of 
solicitude  characteristic  of  younger  men.  Digital  examination  is 
likely  to  show  in  these  cases  thickening  and  perhaps  tenderness  of 
the  seminal  vesicles  and  vasa  deferentixi.     This  state  of  diffuse  hy- 


382  LYDSTON— DISEASES  OE  THE  PEOSTATE. 

perplasia  may  be  mistaken  for  tlie  condition  of  arterio-sclerosis  so 
strenuously  insisted  upon  by  Guyon  and  his  school  as  the  essential 
feature  of  prostatic  hypertrophy;  indeed,  it  may  perhaps  lead  to 
arterio-sclerosis  with  its  attendant  interstitial  fibrosis.  The  author 
is  firmly  convinced  that  chronic  diffuse  inflammation  is  the  founda- 
tion for  many  cases  diagnosed  as  hypertrophy  of  the  prostate,  and 
that  such  chronic  inflammation  may  be  the  result  of  abuse  of  the 
organ,  not  only  by  high  living,  but  by  sexual  over-indulgence  during 
the  patient's  earlier  life. 

MoEBiD   Anatomy. 

Some  thirty  years  ago  the  elder  Gross  said  that  the  morbid  anat- 
omy of  chronic  prostatitis  was  something  which  did  not  exist.  If 
we  were  to  accept  many  of  the  so-called  cases  of  prostatorrhoea  as 
chronic  inflammation  of  the  prostate  the  opinion  of  this  distinguished 
surgeon  might  still  be  accepted  as  authoritative.  As  already  indi- 
cated, however,  a  large  proportion  of  these  cases  are  not  entitled  to 
the  term  chronic  prostatitis,  consisting  as  they  do  merely  of  hyper- 
semia  of  the  prostate  with  attendant  hypersecretion.  Inasmuch  as 
chronic  prostatitis  is  not  essentially  a  fatal  disease,  opportunities  for 
the  post-mortem  study  of  the  disease  are  relatively  rare.  A  sufficient 
number  of  observations  have  been  made,  however,  to  show  not  only 
that  chronic  prostatitis  exists  as  a  pathological  entity,  but  that  its 
morbid  anatomy  presents  well-marked  features. 

In  the  follicular  or  parenchymatous  form  of  chronic  inflammation 
of  the  prostate  there  may  be  little  or  no  alteration  in  the  prostate 
body,  as  shown  on  clinical  examination,  yet  post-mortem  section  of 
the  tissue  shows  an  increase  of  consistency  of  the  prostatic  tissue  in- 
cidental to  a  greater  or  less  degree  of  periglandular  thickening,  i.e., 
interstitial  connective-tissue  hyperplasia.  This  interstitial  change  is 
more  marked  in  patients  toward  middle  age.  It  would  seem  that 
long  continuance  of  the  glandular  inflammation  eventually  determines 
a  greater  or  less  degree  of  chronic  inflammation  of  a  diffuse  charac- 
ter. Diffuse  inflammation  with  considerable  enlargement  of  the 
prostate  in  men  of  middle  age  is  in  all  probability  often  due  to  long- 
continued  glandular  inflammation,  or  to  chronic  hypersemia.  Hyper- 
plasia of  the  epithelium  lining  the  ducts  and  glands  of  the  prostate 
is  a  constant  condition.  The  lymphatics  of  the  organ  may  be  thick- 
ened and  hyperplastic.  These  conditions  of  thickening  and  hyper- 
plasia of  the  glands  are  likely  to  lead  to  an  irregularity  of  contour  of 
the  prostate  which  may  be  mistaken  for  tuberculosis.  The  follicular 
and  racemose  glands  and  their  ducts  are  often  dilated,  usually  irreg- 


CHEONIC  PROSTATITIS.  383 

ularly  so.  Complete  or  partial  occlusion  may  occur  at  certain  points, 
as  a  consequence  of  whicli  retention  cysts  of  muco-pus  and  epitlie- 
lium  may  form.  The  urethral  orifices  of  the  prostatic  ducts  are 
dilated  and  thickened  as  a  rule,  although  in  some  instances  their 
lumen  is  more  or  less  contracted.  Pressure  upon  the  gland  causes 
the  exudation  of  a  muco-purulent  fluid  mixed  with  epithelial  debris. 
The  mucous  membrane  of  the  prostatic  urethra  may  be  compara- 
tively normal,  but  it  is  likely  to  be  thickened,  hypersemic,  and  possi- 
bly granular.  This  condition  of  the  urethra  exists  in  cases  in  which 
chronic  prostato-urethritis  has  been  the  chief  feature  of  the  case. 
The  changes  above  described  are  to  be  expected  in  practically  all  in- 
dividuals who  have  experienced  an  acute  inflammation  of  the  prostate 
at  some  period  more  or  less  remote.  That  such  changes  are  fre- 
quent the  author  has  demonstrated  by  a  large  number  of  post- 
mortem examinations. 

Le  Dentu  has  given  an  excellent  description  of  chronic  diffuse 
prostatitis  in  a  patient  thirty -two  years  of  age  who  died  of  some  in- 
tercurrent disease.  The  prostate  was  greatly  enlarged,  the  right  lobe 
being  especially  so.  The  normal  tissue  of  both  lobes  was  replaced 
by  connective  tissue  presenting  lacunae  varying  in  dimension  from 
the  size  of  a  hemp-seed  to  that  of  a  large  pea.  The  larger  cavities  were 
filled  with  muco-pus  and  were  evidently  formed  by  the  fusion  of 
smaller  cavities. 

The  author's  dissections  show  that  in  well-marked  diffuse  inflam- 
mation of  the  prostate,  the  morbid  process  involves  not  only  the 
prostate  body  proper,  but  the  prostatic  urethra,  the  prostatic  glands 
and  ducts,  the  seminal  vesicles,  vasa  deferentia,  and  the  peri-prostatic 
tissues  which  invest  the  prostate,  neck  of  the  bladder,  seminal  vesi- 
cles, and  vas  deferens.  Thickening  and  induration  of  the  involved  tis- 
sues are  a  marked  feature.  Desnos  and  Kirmesson  have  directed 
especial  attention  to  the  thickening  of  the  submucous  rectal  tissue 
contiguous  to  the  prostate  and  to  the  cellular  tissue  lying  between 
the  latter  organ  and  the  rectum.  Adenitis  with  resulting  enlarge- 
ment of  the  lymphatic  glands  and  a  nodular  condition  of  the  prostate 
which  may  be  felt  from  the  rectum  is  more  likely  to  occur  in  the  dif- 
fuse than  in  the  follicular  or  parenchymatous  form.  This  condition 
is  probably  the  one  which  is  most  often  mistaken  for  prostatic 
tuberculosis. 

In  the  suppurative  variety  of  prostatitis  extreme  dilatation  of  the 
ducts  and  racemose  glands  of  the  prostate  may  exist,  constituting  an 
advanced  stage  of  the  parenchymatous  form  of  inflammation.  The 
pseudo-cysts  are  distended  with  the  i)roducts  of  suppurative  inflam- 
mation— i.e..  muco-pus,  and  epithelial  debris,  in  conjunction  with  the 


384  LYDSTON — DISEASES  OF  THE  PEOSTATE. 

prostatic  secretion  proper.  The  prostatic  tissue  may  be  relatively 
atrophied  by  pressure  mal-nutrition,  while  an  actual  increase  of  bulk 
from  the  neoplastic  formation  exists.  The  cavities  formed  by  occlu- 
sion of  the  prostatic  ducts  and  glands  and  the  accumulation  of  patho- 
logical products  within  them  may  open  into  the  substance  of  the 
glands,  producing  infection  and  extensive  abscess  formation.  True 
abscesses  usually  exist  in  several  forms,  viz. :  a.  There  maj^  be  one 
large  abscess  circumscribed  from  the  beginning  or  formed  by  fusion 
of  several  smaller  pus  cavities;  h.  Disseminated  small  foci  of  sup- 
puration may  exist ;  c.  The  peri-prostatic  tissue  may  be  the  seat  of 
the  abscess.  In  such  cases  a  peripheral  prostatic  abscess  has  in  all 
probability  ruptured  into  the  peri-prostatic  tissue  and  produced  sec- 
ondary infection  in  this  locality.  Thompson  has  encountered  cases 
in  which  several  abscesses  from  the  size  of  a  grain  of  sago  to  that  of 
a  large  pea  were  found  in  the  substance  of  the  gland.  The  prostatic 
utricle  is  sometimes  dilated  and  filled  with  pus.  Large  or  small 
abscesses  often  communicate  with  the  urethra,  in  which  event  they 
are  likely  to  contain  the  products  of  urinary  decomposition.  The 
abscess  cavity  may  communicate  with  the  rectum,  perineum,  blad- 
der, or  urethra.  Abscesses  may  be  found  where  no  symptoms  of 
prostatic  suppuration  existed  during  life.  Civiale  relates  the  case  of 
an  old  man  who  was  under  careful  observation  in  the  Hopital  Necker 
for  twenty  days.  There  was  no  suspicion  of  prostatic  abscess,  yet 
among  the  many  serious  lesions  of  the  genito-urinary  tract  which 
were  found  upon  autopsy  was  a  large  abscess  of  the  left  lobe  of  the 
prostate.  Abscesses  of  this  character  may  be  found  in  almost  any 
chronic  disease  of  the  genito-urinary  tract,  stricture  of  the  urethra 
being  perhaps  most  frequently  followed  by  such  abscesses.  Suppu- 
ration may  occur  as  a  result  of  infection  from  cystitis  or  prostatic 
hypertrophy,  or  vesical  calculus.  When  suppuration  has  occurred 
in  the  course  of  prostatic  hypertrophy  or  of  the  treatment  for  that  con- 
dition, the  prostate  presents  the  ordinary  characters  of  hypertrophy 
associated  with  suppuration.  In  some  instances  the  prostate  atro- 
phies completely  under  the  pressure  of  the  pus.  The  capsule  of  the 
prostate  and  the  peri-prostatic  tissues  under  such  circumstances  un- 
dergo fibroid  transformation  and  form  a  pseudo-cyst  containing  pus 
and  communicating  perhaps  with  the  prostatic  urethra.  Tubercular 
deposits  may  be  found  in  connection  with  chronic  inflammation  of  the 
prostate,  this  condition  being  classified  by  some  authors  as  tubercu- 
lous prostatitis.  The  abscess  under  such  circumstances  may  be  due 
to  one  or  both  of  two  conditions,  namely,  to  caseation  of  tubercular 
tissue  or  to  pus  infection.  Tubercular  prostatitis  merits  fuller  con- 
sideration, which  will  be  given  it  under  the  head  of  prostatic  tuber- 


CHEONIO  PROSTATITIS.  385 

culosis.     It  is  possible  that  in  some  cases  chronic  prostatic  abscess 
is  due  to  suppurative  adenitis  from  mixed  infection. 

Teeatment. 

In  the  follicular  or  parenchymatous  form  of  chronic  prostatitis, 
the  case  is  to  be  regarded  essentially  as  one  of  infection  of  the  mu- 
cous membrane  of  the  prostatic  urethra,  and  of  the  epitheliufa  lining 
the  ducts  and  follicles  of  the  organ.  Its  treatment  is  that  of  so-called 
posterior  urethritis.  It  is  to  be  remembered,  however,  that  in  some 
instances  the  mucous  membrane  of  the  prostatic  urethra  becomes 
comparatively  healthy  while  the  infectious  process  or  its  results  in 
the  glandular  structures  of  the  organ  persist  indefinitely.  Bj  regard- 
ing the  condition  as  a  chronic  follicular  prostatitis  rather  than  a  pos- 
terior urethritis,  the  disease  is  likely  to  be  treated  upon  more  logical 
principles  than  at  the  hands  of  those  who  believe  in  an  infectious 
process  limiting  itself  to  the  jDosterior  or  i^rostatic  urethra  alone. 

The  therapeutics  ,of  the  disease  may  be  divided  for  consideration 
into: 

Hygienic  and  dietetic  measures. 
A.  General.  . .  -j  Remedies  having  a  special  action  on  the  genito-urinary  tract. 
Remedies  to  correct  diathetic  conditions. 


B.  Local. 


f  Mechanical,  by  sounds. 
Irrigations. 
Instillations. 
Medicinal  applications  by  ointments  or  soluble  bougies. 

The  general  treatment  comprises  careful  attention  to  genito-uri- 
nary hygiene,  with  especial  reference  to  the  regulation  of  the  sexual 
functions,  and  the  administration  of  certain  remedies  having  more  or 
less  marked  special  action  upon  the  prostate  and  the  mucous  mem- 
brane of  the  genito-urinary  tract.  There  is  little  hope  of  securing 
much  benefit  from  treatment  unless  the  patient  leads  a  life  of  conti- 
nence and  dietetic  abstemiousness. 

While  from  a  x^athological  standpoint  a  perfect  cure  of  chronic 
prostatitis  rarely  if  ever  occurs,  the  patient  in  a  large  proportion  of 
cases  may  become  practically  well,  if  due  consideration  be  paid  to 
the  time  element  in  treatment  and  judicious  instruction  in  genito- 
urinary and  sexual  hygiene  be  given  and  conscientiously  followed. 
Dilatation  of  the  prostate  by  means  of  the  steel  sound  is  curative  in 
a  certain  proportion  of  cases  in  which  the  inflammation  is  chiefly 
parenchymatous  or  follicular.  Caution  is  necessary  in  selecting  the 
time  for  beginning  the  application  of  the  sound.  It  is  likely  to  be 
injurious  before  the  immSiTy  acute  inflammation  has  entirely  sub- 
sided. It  is  by  no  means  unusual  for  the  early  use  of  the  sound  to 
Vol.  I.— 25 


386  LYDSTON — DISEASES  OF  THE  PEOSTATE. 

excite  a  recurrence  of  acute  prostatic  inflammation.  Sliould  stricture 
of  the  anterior  portion  of  tlie  canal  exist,  urethrotomy  is  usually  in- 
dicated. Strictures  at  or  near  the  meatus  are  especially  liable  to 
aggravate  prostatic  inflammation  on  account  of  the  reflex  irritation 
and  hypersemia  thereby  excited  in  the  deep  urethra  and  its  muscular 
environment.  The  first  indication,  therefore,  in  cases  of  this  kind,  is 
to  free  the  anterior  urethra  of  all  points  of  irritation  and  contraction. 
Many  cases  of  chronic  prostatitis  previously  rebellious  to  all  meas- 
ures of  treatment  will  yield  very  speedily  after  an  anterior  internal 
urethrotomy.  The  results  of  the  operation  in  these  cases  are  ex- 
tremely gratifying.  The  author  desires  to  call  particular  attention 
to  this  feature  of  certain  cases  of  chronic  prostatitis. 

Inasmuch  as  in  a  majority  of  cases  of  chronic  prostatic  inflamma- 
tion there  exists,  either  jDrimarily  or  secondarily,  infectious  inflam- 
mation of  the  prostatic  urethra  and  the  glands  and  ducts  tributary  to 
it,  antiseptic  treatment  in  some  form  is  indicated.  Internal  medica- 
tion by  means  of  eucalyptus  and  the  various  balsamic  preparations 
aids  somewhat  in  antisepsis  of  the  prostatic  urethra,  but  more  direct 
measures  are  usually  necessary  to  accomplish  the  desired  result. 
Where  it  is  possible  to  employ  it,  deep  irrigation  by  means  of  a  short 
urethral  nozzle  is  best  for  this  purpose.  In  by  far  the  majority  of 
patients,  after  a  little  training,  water  can  be  readily  forced  from  the 
anterior  into  the  deep  urethra  and  bladder  without  the  aid  of  either 
catheter  or  irrigating  tube.  In  this  manner  alone  can  the  urethra 
and  bladder  be  thoroughly  irrigated  by  antiseptic  solutions.  There 
are  but  three  remedies  which  are  likely  to  prove  effectual  by  irriga- 
tion. These  in  the  order  of  their  efficiency  are,  in  the  experience  of 
the  author,  first,  permanganate  of  potassium;  second,  nitrate  of  sil- 
ver; iMrd,  bichloride  of  mercury.  Permanganate  of  potassium  may 
be  used  in  the  strength  of  from  1  in  10,000  to  1  in  5,000,  rarely 
stronger.  The  water  should  be  comfortably  warm,  not  very  hot,  as 
it  is  often  used,  and  should  be  employed  in  a  quantity  of  not  less 
than  two  quarts  at  each  irrigation.  In  the  larger  proportion  of  cases 
the  permanganate  of  potassium  is  quite  effectual.  Sometimes,  how- 
ever, it  has  little  effect,  in  which  event  the  nitrate  of  silver  in  weak 
solutions  often  acts  admirablj^  The  solutions  ordinarily  recommended 
are  too  strong.  From  one-half  to  one  per  cent  is  usually  quite  as 
concentrated  as  the  urethra  and  bladder  will  tolerate.  It  is  worthy  of 
remark  that  a  half-per-cent  solution  by  means  of  copious  irrigation 
excites  more  pronounced  reaction  in  the  deep  urethra  and  bladder 
than  do  much  stronger  solutions  used  by  instillation. 

Instillations  of  antiseptic  and  astringent  remedies  by  means  of  the 
deep  urethral  syringe  come  next  in  order.     They  are  highly  extolled 


CHRONIC  PEOSTATITIS.  387 

by  many  of  our  genito-urinary  authorities,  yet  nevertheless  tliey  are 
often  disappointing.  As  made  with  an  ordinary  Ultzmann  syringe  the 
application  of  a  few  drops  of  nitrate  of  silver  solution  to  the  prostatic 
urethra  for  the  cure  of  follicular  prostatitis,  or  so-called  posterior 
urethritis,  is  the  height  of  absurdity.  The  area  medicated  b}^  the 
solution  is  but  a  small  part  of  that  which  is  infected,  and  a  few  drops 
of  a  more  or  less  powerful  solution  of  nitrate  of  silver  are  not  likely 
to  accomplish  much  good.  Where  the  instillation  method  is  used  at 
all,  it  should  be  by  means  of  a  syringe  holding  a  drachm  or  two  of 
fluid.  The  orifices  in  the  injecting  tube  should  be  numerous,  this  ar- 
rangement enabling  the  fluid  to  escape  in  the  prostatic  urethra  simul- 
taneously in  all  directions,  flushing  this  portion  of  the  canal  thor- 
oughly. Such  a  syringe  is  very  convenient  in  cases  where  we  desire  to 
leave  a  certain  quantity  of  antiseptic  or  astringent  fluid  in  the  bladder. 
Nitrate  of  silver,  bichloride  of  mercury,  sulphate  of  thalline,  and 
choloride  of  zinc  are  the  most  reliable  of  the  remedies  in  vogue  for 
instillation.  Astringent  and  antiseptic  remedies  applied  by  means 
of  ointments  or  soluble  bougies  are  often  of  marked  service.  Iodo- 
form is  probably  the  most  valuable  medicament  for  use  in  this  man- 
ner. Nitrate  of  silver  in  combination  with  lanolin,  five  to  twenty 
grains  to  the  ounce,  is  also  frequently  efficacious.  Local  medication 
of  the  prostate  via  the  rectum  is  also  of  service.  Iodoform,  europhen, 
and  ichthyol  in  combination  with  anodynes  are  often  found  efficacious 
in  assisting  in  the  cure  of  the  chronic  inflammation.  They  are  espe- 
cially indicated  where  well-marked  difi^use  inflammation  exists.  In 
such  cases  also  massage  of  the  prostate  and  seminal  vesicles  via  the  rec- 
tum sometimes  proves  beneficial.  Counter-irritation  to  the  perineum 
in  the  form  of  blisters  is  one  of  the  most  valuable  adjuvants  to  the 
treatment.  Frequently  repeated  hot  rectal  injections  in  combination 
with  hot  sitz-baths  are  of  service.  In  obstinate  cases,  prolonged  rest 
in  bed  meets  a  very  important  indication.  Many  cases  of  chronic  in- 
flammation of  the  prostate  may  be  completely  cured  in  this  manner. 
Few  cases  indeed  will  resist  from  four  to  eight  weeks'  complete  rest 
in  the  recumbent  posture.  Due  attention  should  be  paid  to  the  con- 
dition of  the  bowels.  Hepatic  torpor  especially  must  be  counteracted. 
The  pelvic  circulation,  in  short,  should  be  kept  as  active  as  possible 
by  appropriate  remedies.  In  very  serious  cases  of  well-marked 
diffuse  chronic  inflammation,  a  cure  may  be  brought  about  in  a  large 
proportion  of  instances  by  putting  the  prostate  and  neck  of  the  blad- 
der completely  at  rest  by  means  of  combined  suprapubic  and  peri- 
neal section  with  through-and-through  drainage.  Drainage  by  the 
perineum  should  be  kept  up  for  a  couple  of  weeks,  after  which  time 
the  suprapubic  opening  alone  is  to  he  relied  upon.     Sj^eedy  subsidence 


388  LYDSTON — DISEASES  OF  THE  PROSTATE. 

of  the  prostatic  inflammation  is  to  be  expected  in  most  cases.  The 
author  unhesitatingly  recommends  this  method  of  treatment  in  stub- 
born cases,  especially  those  occurring  in  men  at  or  about  middle  age. 

It  is  unnecessary  to  enumerate  the  various  internal  remedies  which 
are  likely  to  prove  of  value.  Anaphrodisiacs,  ergot,  and  most  of  the 
other  remedies  which  have  been  enumerated  as  efficacious  in  hyper- 
trophy of  the  prostate,  and  some  of  those  recommended  in  acute  in- 
flammation of  the  organ,  may  any  of  them  be  quite  beneficial. 

One  of  the  most  important  points  regarding  chronic  inflammation 
of  the  prostate  is  the  fact  that  the  follicular  form  of  gonorrhoeal  origin 
may  afford  an  infectious  secretion  for  a  prolonged  period.  A  pa- 
tient who  has  been  apparently  well  for  many  months  may  infect  the 
female,  not  necessarily  with  true  gonorrhoea,  but  with  some  form  of 
mucous  inflammation  which  is  a  derivative  of  the  original  true  speci- 
fic process.  The  patient  should  be  duly  impressed  with  this  feature 
of  his  disease,  else  he  may  not  appreciate  the  necessity  for  prolonged 
treatment  and  attention  to  hygienic  rules. 

Tuberculosis  of  the  Prostate. 

Tuberculosis  of  the  prostate  was  recognized  many  decades  ago  by 
the  great  French  clinician  Louis.  The  first  contribution  clearly  set- 
ting forth  its  pathological  anatomy  was  that  of  Verdier. 

Since  the  appearance  of  Verdier' s  brochure  on  prostatic  inflam- 
mation a  large  number  of  contributions  upon  the  subject  have  ap- 
peared, and  tuberculosis  not  only  of  the  prostate  but  of  the  genito- 
urinary tract  as  a  whole  is  fairly  well  understood  as  a  definite  morbid 
entity. 

The  subject  has  been  much  more  clearly  defined  since  the 
establishment  of  the  germ  origin  of  disease  upon  a  firm  basis.  It 
must  be  confessed,  however,  that  in  certain  quarters  a  knowledge  of 
the  possibility  of  jjrimary  and  secondary  tubercular  involvement  of 
the  prostate  has  added  an  element  of  confusion  to  the  study  and 
treatment  of  prostatic  disease.  As  is  usually  the  case  with  all  new 
fields  of  pathological  research,  genito-urinary  tuberculosis  has  be- 
come somewhat  of  a  fad,  and  it  is  becoming  quite  fashionable  among 
practitioners  to  classify  most  of  the  obstinate  chronic  cases  of  genito- 
urinary disease  which  come  under  their  observation  as  tubercular. 
This  will  be  refered  to  again  later. 

Varieties. 

Prostatic  tuberculosis  occurs  in  three  forms,  which  are  clinically 
quite  readil}^  differentiated  where  a  positive  diagnosis  is  possible. 


TUBERCULOSIS  OF  THE  PROSTATE.  389 

These  are :  (1)  Primary,  in  wMch,  no  focus  of  infection  more  or  less 
distant  is  discoverable;  in  these  cases  there  is  usually  chronic 
follicular  inflammation  upon  which  the  tuberculosis  is  ingrafted; 
tubercular  disease  may,  however,  occur  without  any  pre-existing 
symptoms  of  chronic  inflammation ;  (2)  Involvement  of  the  prostate 
secondary  to  tuberculosis  in  distant  organs,  the  infection  occurring 
by  way  of  the  general  circulation ;  (3)  Prostatic  tuberculosis  second- 
ary to  disease  of  contiguous  and  correlated  tissues  or  organs.  The 
latter  is  the  most  frequent.  With  regard  to  the  primary  form,  it  is 
open  to  question  whether  antecedent  chronic  inflammatory  disease  is 
not  a  necessary  factor  in  the  etiology. 

Etiology. 

In  the  primary  cases  it  is  possible  that  an  hereditary  or  acquired 
tubercular  predisposition  may  exist.  But  the  most  important  and 
determining  factor  is  usually  chronic  follicular  inflammation.  That 
the  general  health  of  the  patient  is  usually  below  par,  is  a  matter  of 
almost  universal  clinical  experience.  In  such  cases  the  point  of  les- 
sened resistance  to  bacillary  infection  is  afforded  by  the  long-contin- 
ued chronic  inflammation.  In  some  cases  the  patient  has  either  had 
no  antecedent  inflammation  or  he  has  been  subject  to  acute  deep- 
seated  inflammation  involving  the  prostate  and  posterior  urethra 
which  has  so  long  subsided  that  it  seems  unwarrantable  to  attri- 
bute the  symptoms  of  tubercular  infection  to  the  almost  forgotten 
gonorrhoeal  infection.  In  such  cases  it  is  possible  that  the  tubercu- 
lar infection  is  not  preceded  by  chronic  inflammation.  It  is  probable, 
however,  that  hypersemia  from  sexual  excesses,  uugratified  desire,  or 
alcoholism,  or  any  cause  of  pelvic  or  prostatic  congestion  associated 
with  constitutional  debility,  may  prepare  the  soil  for  infection.  More 
often  the  prostatic  tuberculosis  is  secondary  to  tuberculosis  of  asso- 
ciated organs,  such  as  the  penis,  testes,  bladder,  kidneys.  Secondary 
infection  from  testicular  tuberculosis  is  the  most  frequent  of  all.  In- 
volvement of  the  prostate  as  a  secondary  feature  of  renal  tuberculosis 
may  occur  in  one  of  two  ways :  (1)  By  the  lodgment  of  the  bacilli 
can'ied  downward  by  the  urine ;  (2)  In  the  same  manner  as  in  tu- 
berculosis of  the  lungs,  by  infection  through  the  general  circulation. 
Prostatic  tuberculosis  secondary  to  infection  of  distant  and  unas- 
sociated  organs  is  obviously  not  of  so  great  clinical  importance  as 
the  jjreceding  varieties,  inasmuch  as  the  primary  infection,  es- 
I>ecially  of  the  lungs  and  x)eritoneum,  is  usually  intrinsically  fatal,  the 
prostatic  tuberculosis  being  therefore  chiefly  of  j)athological  impor- 
tance, aside  from  attemi>ts  at  palliation  of  the  local  urinary  difficulty. 


390  lydston — diseases  of  the  prostate. 

Morbid  Anatomy. 

This  is  essentially  tlie  same  as  in  tuberculosis  of  other  organs  and 
tissues.  Tlie  characteristic  gray  and  yellow  tubercles,  cavities,  diffuse 
infiltration  and  miliary  deposits,  cretaceous  degeneration,  fibro-scle- 
rotic  change,  and  cicatrization  of  cavities  are  all  found  in  different 
cases  at  different  stages  of  the  disease.  It  is  a  noteworthy  fact  that 
the  more  pronounced  lesions  are  likely  to  be  found  in  primary  tuber- 
culosis of  the  prostate,  or  in  that  form  which  is  secondary  to  disease 
of  contiguous  and  correlated  organs.  Patients  with  prostatic  tuber- 
culosis secondary  to  pulmonary  or  other  serious  forms  of  tubercular 
disease  die  from  the  general  affection  as  a  rule  long  before  the 
prostatic  tuberculosis  has  time  to  develop  serious  lesions. 

A  greater  or  less  degree  of  enlargement  of  the  prostate  is  likely  to 
be  found  sooner  or  later  in  prostatic  tuberculosis.  Enlargement  ap- 
pears earlier  in  cases  in  which  the  periprostatic  lymphatics  and 
glands  are  primarily  involved,  or  in  which  there  is  primary  interstitial 
deposit,  than  in  those  in  which  the  first  manifestation  of  the  disease 
consists  of  a  tubercular  prostatitis  limited  primarily  to  the  mucous 
and  submucous  tissues  of  the  prostatic  urethra.  The  enlargement 
may  be  diffuse,  or  limited  to  one  or  the  other  lobe.  Rarely,  if  ever, 
is  it  symmetrical.  The  enlargement  is  due  to  two  factors :  First,  a 
deposit  of  tubercular  elements,  and  second,  consecutive  inflamma- 
tion and  interstitial  proliferation  of  young  connective  tissue.  It  is 
obvious  that  the  ordinary  features  of  prostatic  tuberculosis  may  at 
any  time  be  modified  by  acute  inflammation  or  abscess  from  mixed 
infection  or  traumatism. 

In  primary  prostatic  tuberculosis  the  enlargement  is  likely  to  in- 
volve both  lobes,  although  unequally.  In  the  secondary  form  of  the 
disease  one  lobe  only  may  be  affected,  although  later  in  the  course 
of  the  disease  both  may  become  involved.  In  cases  secondary  to 
tuberculosis  of  the  testicle,  or  in  which  one  testicle  only  is  enlarged 
as  a  condition  secondary  to  a  deposit  in  the  prostate,  only  one  lobe  of 
the  prostate  is  likely  to  be  implicated,  at  least  primarily.  In  some 
cases  in  which  the  prostatic  disease  is  secondary  to  general  tubercu- 
losis, gray  granulomatous  deposits  may  be  the  initial  process.  It 
would  appear,  however,  that  most  often  the  initial  deposit  consists 
of  characteristic  yellowish  granulomatous  nodules.  These  undergo 
sooner  or  later  more  or  less  softening,  and  perhaps  become  liquefied, 
forming  the  so-called  tubercular  abscess,  the  characters  of  which  may 
closely  approximate  ordinary  abscess  or  true  suppuration,  provided 
secondary  infection  with  pus  microbes  occurs.  The  caseating  nodules 
or  the  yellowish  granulomatous  nodules  may  remain  comparatively 


TUBERCULOSIS  OP  THE  PROSTATE.  391 

quiescent  for  a  long  time.  In  cases  in  which,  secondary  mixed  infec- 
tion occurs,  and  pus  microbes  play  the  most  important  role,  the  pro- 
cess may  assume  a  more  or  less  acute  form  and  a  mistaken  diagnosis 
is  likely  to  be  made. 

Primary  tubercular  deposit  most  generally  occurs  about  the 
acini  of  the  glands.  It  may,  however,  first  invade  the  submucous 
tissue  of  the  prostatic  urethra.  The  deposit  soon  undergoes  casea- 
tion, with  the  final  invasion  of  the  epithelium  of  the  prostatic  urethra 
and  resulting  ulceration  and  perforation  of  greater  or  less  extent. 
This  constitutes  the  so-called  tuberculo-ulcerative  prostatitis,  and  is 
the  form  in  which  a  positive  diagnosis  is  most  easily  made.  In 
other  instances  a  caseating  cavity  at  some  distance  from  the  mucous 
membrane  softens  and  burrows  from  the  free  surface,  finally  opening 
into  the  urethra.  Abscess  cavities  and  ulcers  of  the  prostatic  urethra 
are  soon  followed  by  secondary  mixed  infection  and  perhaps  by  in- 
filtration of  urine,  urinary  abscess,  and  fistula.  These  lesions  present 
no  tendency  to  cicatrization  and  spontaneous  cure.  When  the  entire 
gland  or  one  entire  lobe  is  involved,  the  process  may  extend  chiefly 
toward  the  rectum.  Nodules  are  found  in  the  substance  of  the  gland 
and  are  perceptible  on  rectal  exj)loration.  These  may  be  softened 
down  and  with  or  without  secondary  mixed  infection  form  tubercular 
abscesses  which  open  into  the  periprostatic  cellular  tissue,  constituting 
chronic  periprostatic  abscess,  and  eventually  into  the  rectum.  They 
may  burrow  upward  and  laterally,  forming  large  tubercular  cavities 
in  the  prerectal  tissues.  In  other  instances  they  may  open  into  the 
urethra,  after  which  ordinary  urinary  abscess  forms.  Several  caseat- 
ing foci  may  coalesce,  forming  one  large  irregular  cavity  with  rigid 
and  perhaps  eventually  calcareous  walls.  Calcareous  transformation 
or  fibro-sclerotic  change  of  the  walls  of  the  cavities  with  resorption 
of  their  contents  and  eventually  fibroid  degeneration  and  contraction 
of  the  entire  mass  occur  exceptionally  and  result  in  a  spontaneous 
cure.  In  such  cases  the  condition  of  the  prostate  is  one  of  atrophy, 
cicatricial  contraction,  atnd  partial  destruction  of  the  normal  glandular 
and  muscular  tissue. 

In  extreme  cases  of  tubercular  abscess  the  entire  gland  is  repre- 
sented by  a  pus  sac.  This  may  or  may  not  invade  the  urethra. 
When  it  does  so,  the  urine  enters  the  cavity,  decomposition,  local 
and  perhaps  septic  infection,  and  a  more  or  less  acute  urinary  abscess 
may  result.  The  sinuses  which  form  as  a  result  of  tubercular  ab- 
scess may  burrow  in  various  directions.  They  most  often  open  upon 
the  perineum  in  the  neighborhood  of  the  anus ;  their  next  most  fre- 
quent direction  being  toward  the  rectum,  into  the  cavity  of  which  they 
finally   oijen.      They    have  been    known,  however,  to  open  in  the 


392  LYDSTON — DISEASES   OF   THE   PEOSTATE. 

hypogastric  region  or  some  distance  away  upon  the  abdominal  walls, 
or  thighs.  A  small  primarj^  focus  or  perhaps  several  small  tubercu- 
lar foci  may  remain  quiescent  in  the  prostate  for  many  years,  possi- 
bly for  an  indefinite  period.  This  explains  the  extremely  slow  pro- 
gression of  many  cases  in  which  a  diagnosis  of  prostatic  tuberculosis 
is  made,  admitting  that  quite  a  proportion  at  least  of  such  diag- 
noses are  correct.  The  rule  is,  however,  that  general  infection  and  a 
fatal  result  occur  sooner  or  later.  It  is  ob-\dous  that  a  fatal  result 
occurs  much  earlier  in  cases  in  which  the  prostatic  disease  is  secon- 
darj"  to  tuberculosis  of  other  and  more  important  organs. 

It  is  not  easy  to  determine  the  primary  seat  of  infection  in  prostatic 
tuberculosis.  It  is  often  a  very  perplexing  problem  to  decide  whether 
the  primary  deposit  occurred  in  the  prostate  or  in  some  other 
organ  or  tissue  of  the  body.  Even  when  secondary  to  tuberculosis  of 
contiguous  and  correlated  organs  and  tissues,  it  is  not  always  a  simple 
matter  to  determine  the  precise  relation  between  the  i:)rostatic  and  the 
contiguous  disease,  e.g.,  if  the  prostatic  tuberculosis  is  associated  with 
a  similar  process  in  the  testicle,  it  is  not  always  easy  to  determine 
which  organ  was  the  primary  seat  of  the  disease.  From  a  clinical 
standpoint,  it  is  j)robably  most  generally  believed  that  the  prostatic 
disease  is  secondary  to  that  of  the  ejjididymis.  In  many  cases,  how- 
ever, it  seems  logical  to  infer  that  the  tubercular  infection  has  trav- 
elled from  the  prostatic  urethra  via  the  ejaculatory  duct  and  vasa 
deferentia  to  the  epididymis.  This  may  be  inferred  when  the  symp- 
toms of  prostatic  disease  i)recede  for  some  time  tjie  morbid  changes 
in  the  testicle,  and  where  both  epididj-mes  are  involved  at  about  the 
same  time.  It  must  be  remembered,  however,  that  small  tubercular 
nodules  and  sHght  infiltration  of  the  epididymis  may  exist  for  a  long 
time  prior  to  the  development  of  prostatic  symptoms  without  attract- 
ing the  attention  of  the  patient,  the  first  manifestation  of  disease  from 
the  objective  standpoint  being  referable  to  the  urinary  function.  From 
a  pathological  standpoint,  it  is  said  to  be  fair  to  infer  that  when  the 
process  in  the  prostate  is  far  advanced  and  that  in  the  testis  is  in- 
significant, the  prostatic  tuberculosis  may  be  considered  to  be  the 
primay  condition.  This,  however,  is  not  to  be  accepted  without 
qualification,  inasmuch  as  the  process  in  the  testicle  is  always  slow, 
often  comparatively  innocuous,  and  not  likely  in  a  large  proportion  of 
cases  to  go  on  to  extensive  destruction  unless  some  source  of  mixed 
infection  occurs. 

The  condition  of  the  spermatic  cord  is  apparently  not  a  fair  crite- 
rion from  which  to  decide  the  primary  or  secondary  relation  of  the 
prostatic  to  the  testicular  disease  where  these  two  conditions  coexist. 
It  would  appear  that  infections  of  all  kinds  may  expend  their  violence 


TUBEECUL0SI8   OP  THE  PROSTATE.  393 

upon  what  may  be  termed  from  a  practical  standpoint  the  two  ex- 
tremities of  the  seminal  tube,  the  cord  remaining  healthy.  Tubercu- 
lar adenitis  and  lymphangitis  are  very  important  factors  in  prostatic 
tuberculosis.  As  Lannelongue  iDointed  out,  the  lymphatic  glands  be- 
tween the  bladder,  prostate,  and  rectum  may  be  the  point  of  depar- 
ture. In  such  cases  speedy  softening  with  early  opening  into  the 
rectum  may  occur.  In  some  cases  of  prostatic  tuberculosis  there  is 
general  genito-urinary  infection,  primary  or  secondary.  The  kid- 
neys, bladder,  and  ureters  may  be  involved,  the  infection  having 
travelled  up  from  the  prostate  to  the  kidneys  or  vice  versa.  Instead 
of  this  gradual  extension  of  the  disease  upward  or  downward,  the 
kidneys  may  be  the  primary  seat  of  tubercular  deposit,  the  prostate 
presenting  secondary  tuberculosis  as  a  consequence  of  bacillary  in- 
fection either  by  the  urine  or  in  a  more  roundabout  way  through  the 
general  circulation. 

Symptoms  and  Diagnosis. 

When  the  prostatic  urethra  is  the  seat  of  a  tubercular  deposit 
— with  or  without  involvement  of  the  bladder — the  symptoms  are  es- 
sentially the  same  as  in  any  chronic  inflammation  in  this  region.  Pain 
referred  to  the  region  of  the  bladder,  perineum,  thighs,  groins,  ure- 
thra, testes,  and  rectum  may  be  complained  of  in  different  cases. 
Frequent  and  painful  micturition,  increasing  in  severity  as  the  vesical 
neck  becomes  invaded,  is  the  most  uniform  symptom.  Some  hsema- 
turia  is  observed.  This  is  not  profuse  as  a  rule,  but  is  limited  to  the 
last  few  drops  of  urine.  Sometimes,  however,  it  is  moderately  free, 
and  if  the  urethra  is  involved  anterior  to  the  triangular  ligament 
urethrorrhagia  may  be  observed.  The  fusiform  clot  characteristic  of 
prostatic  hemorrhage  is  sometimes  seen.  Acute  retention  of  urine 
may  occur  from  the  supervention  of  hypersemia,  simj)le  inflammation, 
or  the  formation  of  a  mixed  abscess.  The  urine  contains  muco-pus, 
epithelium,  thready  filaments,  and,  if  ulceration  exists,  particles  of 
tuberculous  tissue  are  sometimes  observed.  A  chronic  prostatic  or 
recurrent  discharge  of  a  muco-purulent  character  is  present  where  the 
prostatic  urethra  is  involved.  Bacilli  may  or  may  not  be  present, 
but  are  rarely  to  be  observed  unless  ulceration  or  abscess  exists.  In 
a  general  way,  the  discharge  is  that  of  a  stubborn  so-called  posterior 
urethritis — i.e.,  follicular  prostatitis.  The  discharge  of  muco-pus  is 
likely  to  be  intermittent,  occurring  only  at  stool,  during  the  coup  de 
pisfxm,  or  on  digital  x>i"e8sure  through  the  rectum.  When  the  dis- 
charge escax)es  si)ontaneously  from  the  meatus,  the  anterior  urethra 
is  also  involved,  notiific^essarily  in  a  tul^ercular  urethritis,  but  inmost 
cases  being  the  seat  of  simx)le  chronic  inflammation.     Sometimes  a 


394  LTDSTON — DISEASES  OF  THE  PEOSTATE. 

large  quantity  of  pus  suddenly  appears  in  tlie  urine.  This  is  indica- 
tive of  tlie  evacuation  of  the  abscess  per  urethram. 

When  the  tubercular  deposit  is  at  the  periphery  of  the  prostate  or 
in  the  periprostatic  tissue,  there  may  be  no  symptoms  for  a  long 
time.  The  patient  is  not  likely  to  complain  unless  the  bladder, 
urethra,  or  testes  become  involved.  There  may  be  some  pain  and 
weight  in  the  perineum,  with  tenderness  upon  pressure,  a  moderate 
amount  of  rectal  tenesmus  and  pain  in  defecation,  but  these  symp- 
toms are  usually  noticeable  only  after  a  sufficient  amount  of  tubercu- 
lar material  has  become  deposited  to  produce  more  or  less  mechanical 
disturbance. 

As  will  be  observed,  there  is  nothing  x>athognomonic  in  the 
foregoing  symptomatology.  The  most  definite  symptoms  are  of  an 
objective  character  and  are  to  be  determined  by  rectal  exploration. 
The  i)rostate  is  found  to  be  the  seat  of  an  irregular  nodular  enlarge- 
ment with  perhaps  areas  of  softening.  A  granular  feel  of  the  peri- 
prostatic tissue  has  been  described.  The  seminal  vesicles  are  sooner 
or  later  involved  as  a  rule  and  are  thickened,  nodular,  and  tender. 
A  definite  abscess  may  be  found.  After  evacuation  of  the  tubercular 
abscess  relative  atrophy  and  perhaps  sclerosis  of  the  prostate  are  ob- 
served. The  passage  of  the  catheter  may  result  in  the  detection  of 
the  abscess  cavity,  usually  upon  the  floor  of  the  prostatic  urethra. 

It  is  obvious  that  it  is  quite  easy  to  make  diagnostic  errors  where 
there  is  no  softening  or  ulceration  of  the  jjrostate.  The  presence  of 
bacilli  in  the  urine  or  pathological  discharge  from  the  affected  organ 
constitutes  the  only  positive  sign  of  tuberculosis.  Since  so  much  has 
been  written  upon  tuberculosis  of  the  genito-urinary  tract,  many  mis- 
takes of  diagnosis  have  been  made.  Among  some  surgeons  the  pres- 
ence of  more  or  less  hardness  of  one  or  the  other  ei^ididymis  with  a 
little  enlargement,  tenderness,  and  nodulation  of  the  prostate  are  suffi- 
cient to  warrant  a  diagnosis  of  prostatic  tuberculosis.  It  must  be 
remembered,  however,  that  simple  chronic  inflammation  of  the  epi- 
didymis may  present  the  same  signs  as  far  as  the  testes  are 
concerned.  Simple  adenitis — periprostatic  adenitis  with  chronic  fol- 
licular prostatitis — ^may  afford  all  of  the  other  signs  upon  which 
the  diagnosis  of  tubercular  disease  of  the  prostate  is  frequently 
based.  In  the  experience  of  the  author,  it  is  nothing  unusual  to 
meet  with  such  cases  that  have  been  diagnosticated  as  tuberculosis 
of  the  prostate.  Under  the  ordinary  measures  of  treatment  of  follicu- 
lar prostatitis  many  of  these  cases  readily  yield.  The  inference  is 
obvious — either  many  cases  of  tuberculosis  of  the  prostate  con- 
stitute a  mild  and  comparatively  harmless  affection,  readily  amenable 
to  treatment,  or  else  frequent  mistakes  in  diagnosis  occur. 


TUBERCULOSIS   OF  THE  PROSTATE.  395 

When  a  sluggish,  slowly  developing,  comparatively  painless  and 
insensitive  enlargement  of  one  or  both  epididymes  exists  with  symp- 
toms of  chronic  prostatic  inflammation  and  a  nodular  enlargement  of 
the  prostate,  as  determined  by  rectal  examination,  a  probable  diag- 
nosis of  prostatic  tuberculosis  is  warrantable.  The  detection  of 
bacilli  in  the  urine  or  discharge,  or  the  formation  of  characteristic 
tubercular  abscesses  and  sinuses,  are  necessary  as  a  rule  for  a  positive 
diagnosis.  In  a  case  presenting  similar  symptoms  as  far  as  the  pros- 
tate is  concerned,  and  at  the  same  time  evidences  of  tuberculosis  of  the 
lungs,  peritoneum,  bones,  or  general  lymphatic  system,  the  inference 
regarding  the  prostatic  disease  is  obvious.  The  heredity  of  the  pa- 
tient and  his  general  condition  are  important  factors  in  the  diagnosis. 

There  is  no  regularity  in  the  course  of  the  disease.  Some  pa- 
tients suffer  very  acutely  at  an  early  period  where  the  urethra  and 
bladder  are  involved.  Others,  especially  when  the  urethra  is  not 
primarily  or  early  invaded,  tolerate  the  condition  for  a  very  long 
time.  Complete  arrest  of  the  disease  and  a  spontaneous  cure  may 
result,  as  is  indicated  in  the  discussion  of  the  morbid  anatomy  of  the 
disease. 

Treatment. 

Where  prostatic  tuberculosis  is  secondary  to  disease  of  other 
important  organs,  the  treatment  is  that  of  the  primary  disease,  except- 
ing in  so  far  as  local  measures  of  palliation  may  be  instituted. 
Where  it  is  primary  or  secondary  to  tuberculosis  of  contiguous 
organs,  the  treatment  of  the  local  difficulty  assumes  a  more  promi- 
nent position.  The  general  treatment  of  the  disease  should  be  based 
upon  the  same  x^rinciples  as  tuberculosis  elsewhere,  due  considera- 
tion being  given  to  tonic  and  alterative  treatment,  nutrition,  and 
change  of  climate.  The  method  of  hypodermic  medication  by  iodine 
and  chloride  of  gold  in  the  form  of  Clark's  solution  offers  some  hope 
of  benefit  or  even  cure.  The  local  treatment  should  consist  first  of 
irrigation  of  the  bladder  and  prostate  with  a  warm  solution  of  boric 
acid,  followed  by  the  instillation  of  iodoform  emulsion.  Iodoform  in 
the  form  of  rectal  suppositories  has  seemed  beneficial.  Instillations 
of  nitrate  of  silver  and  other  irritant  astringent  drugs  are  rarely 
beneficial,  and  are  most  likely  to  prove  injurious ;  it  has  even  been 
asserted  that  such  treatment  may  precipitate  ulceration.  When 
possible  to  do  so,  it  is  best  to  irrigate  the  bladder  and  prostate  by 
means  of  a  short  urethral  tube  rather  than  by  instruments  which 
necessitate  more  or  less  mechanical  irritation  of  the  prostate.  Al- 
though the  x)ractice  is  not  universally  accepted,  the  author  is  convinced 
that  putting  the  bladder  at  rest  and  providing  through-and-through 


396  LYDSTON — DISEASES  OF  THE  PROSTATE. 

drainage  at  an  early  period  of  the  disease  is  likely  to  prove  curative 
in  quite  a  proportion  of  cases.  Wlien  abscesses  form  they  should  be 
evacuated,  scraped,  and  packed  with  iodoform  gauze;  all  sinuses 
should  be  thoroughly  curetted  and  treated  with  iodoform.  Interstitial 
injections  ,of  iodoform  emulsion  into  the  affected  gland  constitute  a 
logical  method  of  treatment  and  are  likely  to  j)rove  of  curative  value. 
Cases  are  reported  where  large  tubercular  abscesses  of  the  prostate 
have  been  opened,  curetted,  and  drained  with  resulting  cure,  but  in 
marked  cases  of  prostatic  tuberculosis  recovery  is  rare.  Sooner  or 
later,  the  bladder,  kidneys,  or  distant  organs  become  secondarily 
affected.  When  prostatic  tuberculosis  is  secondary  to  tubercular  dis- 
ease in  other  important  organs  the  death  of  the  patient  is  inevitable. 

Cancer  of  the  Prostate. 

Malignant  disease  of  the  prostate  is  rare,  yet  it  is  probably  more 
frequent  than  is  ordinarily  supposed,  the  condition  being  often  erro- 
neously diagnosed.  Malignant  disease  of  the  prostate  occurs  in  two 
forms,  namely,  sarcoma  and  carcinoma.  It  is  found  at  the  two  ex- 
tremes of  life,  it  being  exceptional  between  the  ages  of  ten  and  fifty 
years.  It  is  occasionally  found  in  very  young  children.  In  some- 
thing over  eighty -five  per  cent  of  cases  the  malignant  afl'ection  assumes 
the  form  of  carcinoma,  the  remainder  being  of  a  sarcomatous  char- 
acter. Sarcoma  is  the  form  which  is  most  likely  to  be  met  with  in 
young  patients. 

Cancer  of  the  prostate  occurs  in  three  forms:  First,  primary; 
Second,  as  an  infection  secondary  to  malignant  disease  of  contiguous 
organs ;  Third,  by  infection  through  the  medium  of  the  blood.  The 
form  which  is  most  often  seen  is  secondary  to  malignant  disease  of 
the  penis,  testes,  bladder,  or  kidneys.  As  Guy  on  has  shown,  primary 
prostatic  cancer  has  but  little  tendency  to  invade  the  bladder,  but 
speedily  involves  the  lymphatics,  especially  those  of  the  pelvis. 
This  latter  clinical  fact  suggested  to  Guyon  the  term  prostato-pelvic 
cancer.  The  disease  may  be  at  first  circumscribed.  It  is  usually, 
however,  diffuse.  The  capsule  of  the  gland  may  alone  be  affected, 
at  least  primarily.  Eventually  extensive  pelvic  invasion  occurs  with 
involvement  of  the  seminal  vesicles,  base  of  the  bladder  and  some- 
times its  mucous  membrane,  the  rectum,  and  urethra.  Mixed  infec- 
tion and  suppuration  may  eventually  occur. 

Symptoms. 

Frequent  and  painful  micturition  with  hsematuria,  and  if  ulcera- 
tion of  the  prostate  exists,  more  or  less  purulent  discharge,  consti- 


-  CALCULUS  OF  THE  PEOSTATE.  397 

tute  the  main  features  in  tlie  symptomatology  of  the  disease.  The 
pain  is  likely  to  be  most  severe  at  night,  and  is  often  referred  to  the 
region  of  the  rectum.  As  the  pelvic  tissues  become  extensively  in- 
volved, pressure,  irritation,  and  resulting  pain  in  one  or  both  sciatic 
nerves  is  likely  to  develop.  Intrapelvic  pressure  also  may  produce 
more  or  less  obstruction  of  the  iliac  veins  with  oedema  of  the  limbs. 
Constipation  from  mechanical  pressure  upon  the  rectum  may  be  ob- 
served. Marked  cachexia  comes  on  at  a  comparatively  early  period. 
A  fatal  result  is  inevitable. 

Diagnosis. 

In  the  differential  diagnosis,  tuberculosis  and  prostatic  hyper- 
trophy only  are  worthy  of  consideration.  A  hard  nodular  enlarge- 
ment of  the  prostate  with  cachexia,  pronounced  symptoms  referable 
to  the  vesical  neck,  and  extreme  pain  suggestive  of  pelvic  involvement, 
taken  in  connection  with  enlargement  of  the  pelvic  lymphatic  glands 
and  those  of  Scarpa's  triangle,  warrant  a  diagnosis  of  cancer.  When 
cancer  exists  elsewhere  in  the  body,  and  especially  if  it  has  invaded 
organs  contiguous  to,  or  correlated  with,  the  prostate,  the  diagnosis 
is  a  very  simple  matter. 

Treatment. 

Treatment  must  necessarily  be  palliative.  All  radical  attempts 
at  surgical  relief  have  thus  far  failed  of  their  object.  The  author 
believes  that  early  suprapubic  section  and  the  establishment  of  a 
permanent  artificial  urethra  is  the  principal  surgical  indication. 
Great  relief  of  some  of  the  most  annoying  symptoms  of  the  disease 
and  prolongation  of  life  are  likely  to  result  from  the  rest  and  freedom 
from  mechanical  irritation  thus  afforded  the  affected  part. 

Calculus  of  the  Prostate. 

Varieties. 

Prostatic  concretions  or  calculi  are  sometimes  seen.  These  occur 
in  four  forms : 

1.  A  variety  due  to  inspissation  of  the  secretion  of  the  prostatic 
follicles,  in  combination  with  the  deposition  of  earthy  salts ; 

2.  Small  calculi  of  urinary  formation,  which  have  formed  in  the 
kidneys  or  bladder  and  have  become  lodged  in  the  prostatic  urethra ; 

3.  Calculi  due  to  the  deposition  of  urinary  salts  and  mucus  in 
some  y)athological  cryi)t,  or  behind  some  obstruction  of  pathological 
forraati(;n  in  the  prostatic  urethra; 

4.  Phleboliths. 


398  LIDSTON— DISEASES  OF  THE  PEOSTATE. 

Morbid  ANATOiry. 

Concretions  of  tlie  first  variety  are  found  in  the  prostate  post 
mortem,  in  cases  in  which  there  have  been  no  symptoms  referable  to 
the  organ  during  life.  Minute  concretions  of  this  kind  are  some- 
times found  in  the  urine.  They  are  first  of  microscopic  size,  and  in 
the  majority  of  cases  never  attain  sufiicient  dimensions  to  be  of  any 
practical  importance.  As  seen  with  the  microscope,  they  are  small, 
ovoid  bodies  of  a  light  yellow  tint  and  pearly  lustre.  In  the  large 
concretions  the  color  is  a  dark  orange.  When  first  formed  they  are 
soft,  but  later  on  they  become  petrified  and  hard.  They  are  precisely 
similar  to  the  concretions  which  form  in  the  follicles  of  the  tonsil 
and  which  are  occasionally  coughed  up  by  patients  with  chronic 
faucial  disease.  In  elderly  patients  they  may  attain  the  size  of  a  pea 
or  larger,  and  may  be  very  abundant.  Thompson  describes  a  case 
in  which  several  thousand  of  these  concretions  were  visible  micro- 
scopically. They  are  found  in  the  secreting  follicles  and  excretory 
ducts,  constituting  the  parenchyma  of  the  prostate.  The  earthy 
material  is  deposited  very  slowly,  in  concentric  laminae,  as  is  the  case 
with  phosphatic  vesical  calculi.  The  walls  of  several  ducts  and  folli- 
cles may  be  absorbed  and  form  a  single  cavity  within  which  a  num- 
ber of  such  concretions  may  be  found.  When  they  become  larger 
and  the  opening  of  the  cavity  within  which  they  are  contained  com- 
municates freel}^  with  the  j)rostatic  urethra,  the  salts  of  the  urine  are 
deposited  about  them,  and  they  become  genuine  prostatic  calculi. 
Cases  have  been  reported  in  which  the  entire  prostate  was  converted 
by  absorption  into  a  sac  completely  distended  with  small  calculi, 
which  could  be  felt  rolling  under  the  fingers  like  beans  in  a  bag. 
Prostatic  calculi  sometimes  fuse  together  and  form  a  sort  of  cast  of  the 
prostatic  ducts  and  urethra.  A  length  of  four  or  five  inches  has  been 
said  to  have  been  attained.  Thompson  refers  to  a  case  in  which  there 
were  nine  fragments  weighing  altogether  three  and  one-quarter  ounces. 
Chemically,  true  prostatic  calculi  are  composed  chiefly  of  calcic  phos- 
phate and  a  small  quantity  of  ammoniaco-magnesian  phosphate. 
They  never  give  rise  to  trouble  unless  they  are  exceptionally  large,  in 
which  event  they  occasion  a  certain  amount  of  mechanical  disturb- 
ance and  urinary  obstruction. 

Treatment. 

Prostatic  calculi  should  not  be  disturbed,  even  where  their  exis- 
tence is  recognized,  unless  they  give  rise  to  definite  symptoms  or  lie 
within  easy  reach.     If  they  are  removed,  it  should  be  by  perineal 


HYPEETROPHY   OF   THE  PROSTATE.  399 

section.     They  may  cause  abscess,  and  finally  be  discharged  into  the 
urethra,  bladder,  perineum,  or  rectum. 

Calculi  are  often  found  in  the  tissues  about  the  prostate  and  neck 
of  the  bladder  at  some  distance  from  the  prostate  proper. 

Hypertrophy  of  the  Prostate. 

Hypertrophy  of  the  prostate  is  the  most  important  morbid  condi- 
tion of  this  organ  which  comes  under  the  observation  of  the  general 
practitioner.  A  large  proportion  of  individuals  past  middle  age  are 
subject  to  it,  and  those  so  affected  are  most  likely  to  come  primarily 
under  the  notice  of  the  medical  man  rather  than  the  surgeon.  Upon 
the  management  of  the  case,  at  the  time  when  it  first  comes  under  the 
observation  of  the  physician,  the  safety  and  future  comfort  of  the 
patient  largely  depend.  Simple  measures  of  exploration  and  pallia- 
tion at  the  hands  of  many  general  practitioners  are  far  more  danger- 
ous on  the  average  than  radical  operations  undertaken  under  like 
circumstances  by  the  surgeon,  because  of  the  difference  in  tech- 
nique from  the  aseptic  standpoint.  It  is  of  the  greatest  importance, 
therefore,  for  the  physician  to  thoroughly  understand  the  disease, 
and  more  especially  to  appreciate  the  relation  of  bacterial  infection  to 
the  morbid  conditions  produced  by  the  prostatic  enlargement. 

Etiology. 

Few  pathological  conditions  indeed  have  been  the  subject  of  a 
greater  variance  of  opinion  as  to  their  etiology,  than  enlargement  of 
the  prostate.  The  opinions  of  authorities  have  varied  from  the  ag- 
nostic assertion  that  in  the  present  state  of  our  knowledge  we  are 
unable  to  determine  positively  the  cause  of  the  condition,  to  opinions 
as  dogmatic  as  could  be  imagined.  It  is  a  noteworthy  fact  that  most 
of  the  modern  theories  are  fully  as  open  to  criticism  as  some  of  the 
more  ancient  views.  Thus  there  is  much  of  logic  in  the  opinion  of 
Home,  who  some  seventy-five  years  ago  promulgated  the  theory 
that  the  principal  cause  of  prostatic  disease  was  slow  return  of  blood 
from  the  neck  of  the  bladder,  arising  from  the  disadvantageous  situ- 
ation of  the  veins  as  regards  their  relation  to  the  heart,  which  favors 
habitual  congestion  of  these  vessels.  He  held  the  opinion  that  this 
tendency  to  congestion  was  enhanced  by  high  living,  or  any  other 
circumstance  which  increased  the  circulation  of  the  blood  in  this 
region.  •  Home  believed  that  traumatism,  such  as  is  incidental  to 
horseback  riding,  sometimes  i)roduced  in  deeper  parts  of  the 
prostate  a  rupture  of  blood-vessels  which  was  subsequently  followed 


400  LYDSTON — DISEASES  OF  THE  PKOSTATE. 

by  hypertrophy.  This  rupture  of  vessels  he  believed  to  be  in  some 
measure  analogous  to  apoplexy.  He  also  assigned  to  old  age  a 
prominent  role  in  the  production  of  hypertrophy  of  the  prostate. 

Wilson,  in  1821,  indorsed  the  opinion  of  Home  so  far  as  the  ten- 
dency to  the  disease  on  the  part  of  high  livers  Avas  concerned. 
He  seemed  to  think  that  strict  celibacy  on  the  one  hand,  and  venereal 
excess  on  the  other,  were  alike  potent  in  the  production  of  the  dis- 
ease, although  he  admitted  that  exceptional  cases  occurred  in  which 
enlargement  of  the  prostate  developed  in  people  who  lived  abstemi- 
ous and  temperate  lives. 

Sir  Charles  Bell  asserted  the  existence  of  a  predisposition  to  pros- 
tatic enlargement,  but  did  not  state  what  constituted  or  caused  this 
predisposition.  Admitting  that  such  predisposition  existed,  he  be- 
lieved that  the  exciting  causes  were  associated  with  irritation  of  the 
bladder  and  the  resulting  frequent  contractions  of  that  viscus.  As  a 
consequence  of  these  contractions  of  the  bladder,  he  believed  that  the 
urethral  muscles  were  the  seat  of  over-action,  the  result  of  which  was 
to  draw  back  the  so-called  median  lobe  in  such  a  manner  as  to 
elevate  it  and  constitute  obstruction  to  the  escape  of  urine. 

Samuel  Cooper  frankly  confessed  that  the  causes  of  prostatic 
hypertrophy  were  unknown.  He  seemed  to  think  from  his  experi- 
ence, however,  that  people  who  led  sedentary  lives  were  more  liable 
to  the  affection  than  others. 

Astley  Cooper  arbitrarily  stated  that  hypertrophy  of  the  prostate 
was  the  consequence  of  old  age  alone,  and  not  of  disease. 

Brodie  seemed  to  think  that  enlarged  prostate  was  a  matter  of 
course  in  old  men.  He  believed  that  prostatic  hypertrophy  never 
becomes  manifest  until  plainly  marked  evidences  of  senility  have  de- 
veloped. 

The  late  Dr.  Gross  expressed  himself  to  the  effect  that  prostatic 
hypertrophy  might  result  from  habitual  engorgement  of  the  organ 
incidental  to  protracted  and  repeated  sexual  intercourse,  irritation 
from  a  vesical  calculus,  the  free  use  of  stimulating  diuretics  and  alco- 
holic or  malt  liquors,  exposure  to  cold,  the  suppression  of  cutaneous 
diseases,  gout  and  rheumatism,  or  traumatism,  to  the  frequent  in- 
troduction of  the  catheter,  and  to  habitual  straining  at  stool,  as  in 
chronic  diarrhoea  and  other  affections  of  the  bowels. 

Mercier  classed  as  predisposing  causes  all  conditions  and  influ- 
ences which  favored  sluggishness  of  the  circulation.  According  to 
him,  men  of  lymphatic  habit,  with  plenty  of  cellular  and  adipose  tis- 
sue, have  generally  a  lax  and  unresisting  venous  system.  Such  sub- 
jects, he  claimed,  are  most  frequently  the  victims  of  prostatic  enlarge- 
ment.    He  believed  that  sedentary  habits  favor  the  disease. 


HYPERTEOPHY  OF  THE  PROSTATE.  401 

Amussat  stated  that  syphilis,  a  foreign  body  in  the  bladder,  and 
stricture  of  the  urethra  were  the  most  common  causes  of  prostatic 
enlargement.  It  is  observed,  he  claimed,  chiefly  in  elderly  persons 
who  have  for  a  long  time  used  sounds  or  bougies  upon  themselves. 

Desault  held  that  enlarged  prostate  was  very  common  in  elderly 
men  and  those  who  have  had  numerous  attacks  of  gonorrhoea.  He 
also  believed  that  the  disease  might  bear  a  certain  relation  to  scrofula 
and  other  cachexise. 

Civiale,  in  discussing  the  etiology  of  prostatic  hypertrophy,  placed 
vesical  calculus  first  in  the  order  of  prominence.  Second  only  to 
vesical  calculus,  he  considered  organic  stricture  of  the  urethra.  He 
denied  the  relation  of  venereal  excesses  to  chronic  prostatic  disease. 

Coulson  contents  himself  with  the  presentation  of  the  views  of 
others  and  has  no  definite  opinion  of  his  own. 

Thompson  expresses  himself  in  the  most  unequivocal  fashion  as 
believing  that  prostatic  enlargement  is  seen  in  young  patients ;  the 
organ  in  such  cases  becoming  enlarged  by  interstitial  plastic  effu- 
sion, the  result  of  inflammatory  action,  while  in  old  age  there  is 
unnatural  development  of  the  prostatic  tissue  proper,  i.  e. ,  true  hyper- 
trophy. According  to  him  the  action  of  inflammation  and  its  pro- 
ducts does  not  favor  growth,  but  is  directly  antagonistic  to  such  a 
process.  A  prostate,  therefore,  which  has  been  enlarged  by  inflam- 
matory effusion  is,  according  to  Thompson,  probably  less  likely  sub- 
sequently to  exhibit  an  hypertrophic  tendency.  Nutrition  is  thus 
impeded,  not  encouraged.  In  brief,  Thompson  feels  warranted  in 
excluding  iiLflammation  from  the  list  of  causes.  Urethral  stricture 
and  calculus  are  not  considered  by  him  to  be  of  great  importance  in 
the  etiology  of  prostatic  hypertrophy.  He  does  not  believe  that 
habitual  engorgement  of  the  prostatic  and  hemorrhoidal  plexuses  has 
much  to  do  with  the  etiology  of  the  disease.  "True  hypertrophy," 
according  to  him,  "  in  any  situation  never  has  venous  congestion  for 
a  cause;  venous  congestion  impairs  structure  and  predisposes  to 
ulceration  of  the  tissues  affected  by  it,  but  it  never  augments  vital 
force  or  stimulates  growth."  Upon  this  ground  Thompson  denies 
congestion  as  a  possible  ground  of  hyjjertrophy  of  the  prostate.  He 
further  disputes  the  possibility  of  rheumatism,  gout,  or  syphilis  play- 
ing any  part  in  the  pathological  process.  Eegarding  the  effect  of 
sexual  excesses,  he  says :  "  Much  influence  has  been  attributed  to  the 
effect  of  habitual  indulgence  of  this  kind;  but  from  the  fact  that 
the  affection  has  been  observed  to  occur  in  individuals  known  to  have 
been  remarkable  for  chastity,  the  opposite  extreme  of  continence 
has  been  regarded  as  exercising  a  similar  influence.  In  regard  to  the 
first,  it  appears  reasonable  to  believe  that  repeated  use  might  induce 
Vol.  I.— 20 


402  LTDSTON — DISEASES   OP  THE  PEOSTATE. 

hypertrophy  here  as  elsewhere.  Without  entering  upon  the  ques- 
tion of  the  prostatic  function,  it  is  impossible  not  to  associate  the 
organ  with  the  sexual  act,  and  admitting  this  it  appears  not  to  be 
easy  to  escape  the  inference  that  hypertrophy  is  likely  to  result  from 
sexual  excess ;  yet  facts  do  not  favor  this  view.  Hypertrophy  does 
not  exist  when  the  function  is  in  greatest  vigor  and  is  not  called  into 
immediate  existence  by  the  most  licentious  excesses  indulged  in  dur- 
ing the  prime  of  life,  and  it  I'nust  be  admitted  that  in  any  part  of  the 
body  hypertrophy  develops  itself  coincidentally  with,  or  at  all  events 
immediately  follows,  the  increased  action  which  induces  it. " 

Although  Thompson  disputes  the  view  that  the  prostate  is  truly 
a  secreting  gland,  he  admits -it  for  the  sake  of  argument,  and  claims 
that  no  other  gland  offers  a  pathological  parallelism  with  hyper- 
trophy of  the  prostate;  all  of  its  component  issues  not  being  in- 
creased in  their  relative  proportions.  An  enlargement  of  the  gland 
may  be  due  to  an  increase  of  glandular  elements ;  or,  on  the  other 
hand,  to  a  change  in  the  structure  and  an  increase  in  the  bulk  of  the 
"prostatic  tissue  proper."  Thompson  does  not  believe,  furthermore, 
that  an  enlargement  of  the  prostate  is  a  simple  muscular  hypertrophy 
induced  by  increased  action.  He  called  attention  to  the  close  simi- 
larity between  the  uterus  and  the  prostate,  and  seems  to  think  that  "  just 
as  during  the  latter  part  of  the  period  of  reproductive  activity  the 
uterus  is  prone  to  develop  new  growths  identical  in  structure  with  its 
own,  a  similar  tendency  will  be  found  to  develop  new  growths  in  the 
prostate  at  a  corresponding  period  in  life  of  the  male."  Thompson's 
tables  apparently  support  the  view  which  he  jjromulgates  by  showing 
that  hypertrophy  of  the  prostate  is  a  disease  incidental  to  old  age, 
but  he  fails  to  make  clear  the  precise  connection  between  advancing 
age  and  the  development  of  prostatic  hyjjertrophy.  Even  granting 
that  old  age  is  the  chief  factor  in  the  production  of  the  disease,  there 
is  yet  much  to  be  accounted  for.  Why  should  so  large  a  proportion 
of  elderly  men  present  a  condition  so  distinctly  pathological,  affecting 
an  organ  which  in  old  age  at  least  should  be  practically  of  no  impor- 
tance from  a  physiological  or  functional  standpoint?  Thompson 
himself  admits  that  hypertrophy  of  the  prostate  is  not  necessarily  or 
even  usually  present  in  old  age,  but  is  rather  an  exceptional  condi- 
tion. According  to  him,  a  slight  tendency  to  hypertrophy  of  the 
prostate  undetermined  during  life  may  exist  in  about  one  in  three 
individuals  after  sixty  years,  and  that  a  marked  enlargement  may  be 
met  with  in  any  one  out  of  seven  or  eight  after  that  age.  Among 
forty  prostates  of  elderly  men  dissected  by  Thompson  only  32  per 
cent  were  appreciably  enlarged,  and  but  2  per  cent  sufficiently  so  to 
have  produced  symptoms  during  life. 


HYPERTEOPHY  OP  THE  PROSTATE.  403 

The  modern  French  school,  following  the  distinguished  Guyon, 
entertains  the  peculiar  view  that  enlargement  of  the  prostate  is  not  a 
local  condition  and  the  effect  of  local  causes,  but  that  all  the  urinary 
organs,  and  particularly  the  bladder,  undergo  changes  of  analogous 
character,  the  origin  of  which  should  be  looked  for  in  structures 
bearing  absolutely  no  anatomical  relation  to  the  urinary  system; 
implying,  in  short,  that  enlargement  of  the  prostate  is  dependent 
upon  general  atheroma.  Thus  this  school  claims  that  the  walls  of 
the  bladder  fail  in  their  power  with  a  resulting  accumulation  of  resid- 
ual urine  followed  by  cystitis,  prior  to  the  enlargement  of  the  pros- 
tate. Reginald  Harrison  has  also  asserted  that  the  habit  of  partial 
retention  frequently  precedes  the  vesical  signs  of  prostatic  enlarge- 
ment, the  depression  of  the  posterior  wall  of  the  bladder  being  a 
primary  change.  In  this  the  author  heartily  concurs.  Harrison 
further  holds  that  the  depression  of  the  posterior  wall  of  the  bladder 
results  in  a  compensatory  hypertrophy  which  determines  the  develop- 
ment of  a  strong  muscular  band  or  buttress  at  the  base  of  the  trigone, 
and  finally  enlargement  of  the  prostate  itself. 

It  is  obvious  that  even  though  we  admit  that,  in  certain  cases,  de- 
pression of  the  floor  of  the  bladder  and  alteration  in  the  walls  of  the 
viscus  precede  perceptible  pathological  change  in  the  prostate,  this 
condition  may  in  no  way  be  causative  of  the  prostatic  disease.  I  con- 
tend that  such  cases  are  no  argument  against  what  appears  to  me  to 
be  the  correct  view,  viz. ,  that  serious  pouching  of  the  bladder  is  gen- 
erally a  secondary  condition.  General  atheroma,  for  example,  with 
a  resulting  alteration  of  the  structure  and  power  of  the  bladder,  might 
occur  and  subsequently  become  associated  with  hypertrophy  of  the 
prostate,  which  condition  is  due  to  the  same  causes  as  in  other  cases 
in  which  prostatic  hypertrophy  is  unassociated — primarily  at  least — 
with  disease  of  the  bladder. 

Much  of  the  obscurity  of  origin  of  prostatic  hypertrophy  is 
probably  due  to  the  clinical  fact  that  the  primary  condition  which 
precedes  true  hypertrophy  is  rather  exceptionally  brought  to  the 
attention  of  the  surgeon.  A  certain  amount  of  diffuse  hyperplasia 
from  prolonged  hypergemia  incidental  to  various  causes  of  irritation 
in  all  probability  exists  in  many  men  under  middle  age.  It  is  not, 
however,  until  distinct  hypertrophy  or  hyperplasia  has  occurred  that 
definite  symptoms  are  complained  of.  In  fatal  cases  the  process  is 
so  far  advanced  as  to  bear  very  little  resemblance  to  the  chronic  en- 
gorgement and  simple  hyperplasia  which  constituted  the  initial  stage 
in  the  so-called  hypertrophic  process.  Concerning  Thompson's  views 
in  regard  to  inflammation  or  circulatory  disturbance  as  factors  in  the 
etiology  of  prostatic  hyfjertrophy,  this  much  may  be  said, viz.,  Chronic 


404  LYDSTON — DISEASES   OF  THE  PEOSTATE. 

congestion  and  inflammation  do  not  produce  true  hypertropliy  it 
is  true,  but  they  do  produce  hyperplasia,  especially  where  the  circu- 
lation is  impeded  by  the  relatively  dependent  position  of  the  part. 
The  hyperactivity  of  the  part  induced  by  the  resulting  irritation  will 
explain  the  true  hypertrophic  element  of  the  disease,  which  as  a  mat- 
ter of  fact  is  subordinate  to  the  hyperplasia.  This  argument  is 
especially  true  as  applied  to  the  prostate,  which  is  a  glandulo-muscu- 
lar  organ. 

Racial  peculiarities  seem  to  have  a  marked  influence  in  the  etiology 
of  hypertrophy  of  the  prostate.  It  is  met  with  in  the  negro  but 
rarely.  Dr.  Hunter  McGuire,  states  that  he  has  never  found  an  ex- 
ample of  it  in  the  pure-blooded  negro,  but  has  seen  several  in- 
stances of  it  in  mulattoes.  Other  surgeons  in  the  Southern  States 
have  met  with  the  disease  in  pure  bloods. 

The  causes  of  the  disease,  according  to  the  views  of  the  author, 
may  be  classified  as  follows : 

(  Senility. 
General  causes. ...  -I  The  gouty  or  rheumatic  diathesis. 
(  General  atheroma. 


Local  causes. 


'  Chronic  irritation   and   hyperaemia    due    to    urethral    or 
bladder  disease. 
Masturbation. 
Sexual  excesses. 
Prolonged  and  ungratifled  sexual  excitement. 

It  is  obvious  that  the  local  and  general  etiological  factors  are  most 
effective  when  associated.  It  is  true  that  these  causes  are  not  recog- 
nized by  most  modern  authorities,  yet  in  my  opinion  such  etiological 
deductions  are  based  upon  sound  physiological  reasoning,  taking 
into  consideration  the  structure  and  function  of  the  organ.  The 
prostate  is  one  of  the  most  important  organs  associated  with  the 
sexual  function.  It  is  particularly  important  from  the  fact  that  it 
is  the  seat  of  sexual  sensibility  and  is  intimately  involved  with  the 
venereal  orgasm.  One  of  the  most  important  elements  in  the 
sexual  act  is  active  hypergemia  of  the  prostate,  and  it  seems  plausible 
from  this  fact  alone  that  excessive  sexual  indulgence  may  produce 
permanent  injury  to  the  organ.  Should  sexual  excesses  be  alter- 
nated with  prolonged  and  ungratifled  sexual  desire,  a  permanent  im- 
pression will  be  stiU  more  likely  to  result.  Constant  over-stimula- 
tion of  the  glandular  tissues  of  the  prostate  is  a  very  important 
element  for  consideration. 

The  enlargement  of  the  prostate  produced  by  chronic  hyperaemia 
is  usually  of  no  particular  importance,  from  a  mechanical  standpoint, 
during  the  youth  or  early  adult  life  of  the  individual.     This  is  prob- 


HYPERTROPHY  OP  THE  PROSTATE.  405 

ably  explicable  by  the  relief  afforded  by  free  secretions,  by  the  elas- 
ticity of  the  tissues  themselves,  and  by  the  fact  that  the  bladder 
retains  its  normal  tonus  for  some  time.  When,  however,  the  indi- 
vidual passes  the  prime  of  life  and  his  tissues  become  less  resilient  and 
secretion  in  general  less  active,  if  the  hypersemia  continues,  there  is 
less  secretion  and  a  diminished  activity  of  the  return  circulation,  with 
consequently  less  relief  of  the  condition  of  relative  hyperemia. 

Few  authorities  at  the  present  day  attribute  as  much  importance 
to  prolonged  irritation  and  habitual  engorgement  of  the  prostate  from 
various  causes  as  did  the  elder  Gross,  but  it  is  the  author's  opinion 
that  the  etiological  factors  outlined  by  this  distinguished  surgeon 
were  based  upon  sound  reasoning  and  accurate  clinical  observation. 
Any  condition  of  the  urethra  which  gives  rise  to  prostatic  irritation 
and  hypersemia  or  to  actual  inflammation,  may  lead  to  permanent  irri- 
tability of  the  vesical  neck,  with  a  resulting  increase  in  the  frequency 
of  urination  which  may  become  a  permanent  condition.  It  seems 
reasonable  that  such  a  condition  may  produce,  later  in  life,  hyper- 
trophy of  the  overworked  prostate  when,  as  is  likely  to  be  the  case, 
undue  sexual  excitement  or  indulgence  coexists  with  the  urinary  irri- 
tation. The  gouty  and  rheumatic  diatheses  probably  bear  a  subordi- 
nate relation  to  the  etiology  of  hypertrophy  of  the  prostate  in  certain 
cases. 

In  a  general  way,  it  may  be  said  that  the  various  etiological  fac- 
tors outlined  are  productive  of  prostatic  overstrain,  which  bears  the 
same  relation  to  prostatic  hypertrophy  that  a  long-forgotten  strain, 
experienced  during  early  life,  sometimes  does  to  a  stiffened  and 
thickened  joint  in  the  aged.  It  is  a  matter  of  common  experience 
that  when  an  individual  well  along  in  years  begins  to  lose  that  elas- 
ticity which  characterized  his  tissues  in  youth,  when  his  joints  begin 
to  grow  less  mobile  and  he  is  inclined  to  rheumatoid  and  other  senile 
difficulties,  special  complaint  is  likely  to  be  made  of  so-called  rheu- 
matism or  rheumatoid  arthritis  limited  to  some  joint  which  has  expe- 
rienced an  injury  at  some  remote  period.  Many  injuries  experienced 
in  youth,  and  long  forgotten,  are  called  to  mind  by  some  pathological 
change  supi)osed  to  be  incident  to  senility.  It  is  hardly  conceivable 
that  so  large  a  proportion  of  mankind  should  be  affected  with  pros- 
tatic hypertrophy  if  there  were  no  special  causes  for  the  condition 
such  as  those  above-mentioned.  Prostatic  hypertrophy  is  certainly 
not  a  natural  concomitant  of  advanced  life,  and  it  is  probable  that 
the  various  causes  which  have  been  mentioned  bear  the  same  relation 
to  it  that  frequent  child-bearing  does  to  certain  i)athological  condi- 
tions of  the  uterus.  It  is  a  noteworthy  fact  that  the  majority  of 
authorities  who  do  not  frankly  acknowledge  that  they  are  unable  to 


406  LYDSTON— DISEASES  OF  THE  PKOSTATE. 

assign  the  disease  to  any  particular  cause,  dwell  with,  greater  or  less 
emphasis  on  the  dependence  of  the  disease  upon  conditions  which 
produce  irritation  and  hypersemia  of  the  organ.  It  is  also  worthy  of 
note  that  the  operation  of  castration  recently  advocated  for  enlarged 
prostate,  has  in  several  cases  been  beneficial.  This  has  a  direct 
bearing  upon  the  etiological  views  above  outlined. 

Prostatic  enlargement,  as  shown  in  the  resume  of  opinions  upon 
its  etiology,  has  been  attributed  to  stricture.  Stricture  of  the  ure- 
thra is  undoubtedly  capable  of  producing  chronic  congestion  and 
hyperplasia  of  the  prostate — i.e.,  overstrain  with  resulting  circula- 
tory disturbance.  Paradoxical  as  it  may  seem,  however,  the  danger 
of  resulting  prostatic  hypertrophy  is  inversely  to  the  degree  of  ob- 
struction. Strictures  of  large  calibre  in  the  penile  portion  of  the  canal 
produce  proportionately  greater  reflex  disturbance  of  the  prostate 
than  deep  strictures  of  small  calibre.  A  man  who  at  the  age  of 
from  thii-ty  to  forty  develops  a  tight  stricture  in  the  deep  urethra  is 
likely  to  be  perfectly  protected  from  enlarged  prostate  in  after-life. 
Irritation  and  congestion  of  the  prostate  occur,  it  is  true,  but  hyper- 
plasia of  that  portion  of  the  organ  which  is  most  likely  to  produce 
urinary  obstruction  is  prevented  by  the  pressure  of  the  urine  in  the 
prostatic  urethra  during  micturition.  The  author's  exi3erience  in  the 
performance  of  perineal  section  upon  tight  strictures  in  the  musculo- 
membranous  region  is  that  the  prostatic  urethra  is  often  dilated,  ap- 
parently at  the  expense  of  the  prostate  itself,  or  at  least  that  portion 
immediately  contiguous  to  the  mucous  membrane  lining  the  prostatic 
urethra.  The  effects  of  pressure  in  producing  relative  prostatic 
atrophy  are  well  shown  in  cases  of  calculi  which  become  lodged  in 
the  prostatic  urethra.  There  may  be,  it  is  true,  compensatory  hyper- 
trophy of  the  remaining  fibres  of  the  prostate,  but  we  must  not  forget 
what  seems  to  be  a  logical  analogy,  viz.,  the  hypertrophy  of  the 
heart  followed  by  extreme  dilatation  which  results  from  obstructive 
valvular  lesions. 

Yaeieties. 

Hypertrophy  of  the  prostate  presents  itself  in  several  different 
forms,  depending  mainly  upon  the  arrangement  of  the  elements  com- 
posing the  abnormal  growth.  It  is  occasionally  associated  with  athe- 
romatous degeneration  and  thickening  of  the  walls  of  the  bladder, 
the  prostate  being  diffusely  enlarged  and  the  anatomical  characters 
of  the  bladder  changes  and  prostatic  overgrowth  being  approximately 
the  same.     In  a  general  way,  the  varieties  are  as  follows : 

1.  Diffuse  enlargement  of  the  gland  associated  with  atheroma  of 
the  bladder.     Exceptionally,  circumscribed  development  of  the  pos- 


HYPERTROPHY  OF  THE  PROSTATE.  407 

terior  median  or  one  of  the  other  lateral  lobes  may  be  associated  with 
vesical  atheroma.  As  a  rule,  however,  where  vesical  atheroma  is 
found,  the  prostate  is  uniformly  enlarged.  In  this  variety  the  thick- 
ening of  the  bladder,  esj)ecially  that  portion  immediately  contiguous 
to  the  prostate,  is  likely  to  be  considerable,  the  vasa  deferentia, 
seminal  vesicles  and  possibly  the  ureters,  participating  in  the  athero- 
matous process,  the  connective  tissue  enveloping  these  structures 
being  greatly  thickened  by  the  atheromatous  deposit,  producing  a 
gristly  or  semi-cartilaginous  condition  of  the  tissues.  Rigid  columns 
of  atheromatous  tissue  are  likely  to  project  into  the  bladder.  In 
some  instances  columns  of  this  sort  correspond  to  the  course  of  the 
ureters  and  vasa  deferentia.  A  bar  between  the  ureteral  orifices  is 
common  in  this  condition. 

2.  Diffuse  enlargement  without  atheroma  of  the  bladder. 

3.  Hypertrophy  of  both  lateral  lobes,  the  median  portion  of  the 
prostate  remaining  comparatively  normal. 

4.  IIypertroi)hy  of  both  lateral  lobes  associated  with  jiosterior 
median  hypertrophy,  so-called  hypertrophy^  of  the  middle  lobe. 

5.  Hypertrophy  of  one  lateral  lobe  associated  with  posterior 
median  hypertrophy. 

6.  Posterior  median  hypertrophy  with  little  or  no  enlargement  of 
the  rest  of  the  organ.  The  overgrowth  may  present  a  quite  acute 
prominence  in  the  median  line  or  may  be  more  or  less  irregular,  filling 
up  the  vesico-urethral  orifice  and  projecting  to  one  or  the  other  side. 

7.  Hypertrophy  of  the  anterior  portion  of  the  prostatic  floor. 
This  may  or  may  not  be  associated  with  hypertrophy  of  one  or  both 
lateral  lobes.     The  latter  is  most  frequent. 

8.  Some  form  of  jjrostatic  hypertrophy  associated  with  bar  at  the 
neck  of  the  bladder. 

9.  Distinct  circumscribed  fibro-adenomatous  tumors  occurring  in 
some  part  of  the  gland.  These  are  somewhat  analogous  to  the  fibro- 
myomatous  neoplasms  which  develop  in  the  uterus.  When  these 
new  growths  occur  in  the  floor  of  the  prostatic  urethra  they  may  form 
quite  distinct  pedunculated  tumors.  In  some  instances  they  project 
from  the  posterior  median  portion  into  the  bladder  and  act  after  the 
manner  of  a  ball  valve  in  producing  urinary  obstruction. 

When  the  prostate  is  diffusely  enlarged  the  mass  may  not  cause 
so  much  difficulty,  even  when  it  is  very  large,  as  is  produced  by 
irregular  development  associated  "  with  deviation  of  the  prostatic 
urethra  and  obstruction  of  the  vesical  neck.  It  seems  that  it  is  not 
the  degree  but  the  variety  of  enlargement  which  is  most  important. 
A  very  large  gland  may  sometimes  be  tolerated,  while  a  very  small 
median  obstruction  often  gives  rise  to  great  annoyance.     It  is  prob- 


408  LYDSTON — DISEASES  OP  THE  PEOSTATE. 

able  tliat  in  many  cases  of  prostatic  liypertropliy  the  process  is  at 
tlie  beginning  of  an  adenomatous  character,  affecting  tlie  glandular 
structures  of  the  organ.  As  the  process  advances  fibro-sclerotic 
changes  develop  and  eventually  the  enlargement  appears  in  the  form 
of  a  fibro-adenomatous  development.  In  all  the  varieties  of  pros- 
tatic hypertrophy  it  is  probable  that  there  is  not  only  hypertrophy  of 
the  elements  of  the  organ  but  a  true  hyperplasia,  which  primarily  at 
least  is  the  predominating  condition.  It  is  a  serious  question  as  to 
whether  the  process  should  not  be  termed  hyperplasia  rather  than 
hypertrophy  of  the  prostate.  Certainly  the  increase  in  bulk  is  due 
more  especially  to  an  increase  of  the  normal  tissue  elements  rather 
than  to  an  exaggerated  development. 

The  most  frequent  variety  of  prostatic  enlargement  is  that  in 
which,  with  or  without  enlargement  of  the  lateral  lobes,  posterior 
median  hypertrophy  exists  forming  the  so-called  middle  lobe.  This 
form  of  hypertrophy  is  also  the  most  important  because  of  the  fact 
that  a  comparatively  slight  overgrowth  in  this  situation  produces  an 
amount  of  mechanical  obstruction  and  irritation  of  the  vesical  neck 
which  is  greatly  disproportionate  to  the  degree  of  the  enlargement. 
The  form  of  median  hyi)ertrophy  varies  considerably.  In  some 
cases  a  distinct  fibro-adenomatous  overgrowth  of  pedunculated  form 
is  met  with.  This,  as  already  suggested,  is  likely  to  have  a  valve- 
like action  producing  intermittence  of  the  stream  of  urine  during 
micturition,  with  perhaps  more  or  less  spasmodic  action  of  the  part 
about  the  neck  of  the  bladder  which  is  strongly  suggestive  of  vesical 
calculus.  Cases  presenting  this  form  of  hypertrophy  are,  other 
things  being  equal,  quite  amenable  to  surgical  interference,  inas- 
much as  the  necessary  operation  is  very  simple,  and  if  it  be  performed 
at  an  early  period  before  the  kidneys  are  extensively  diseased,  the 
result  is  likely  to  be  excellent.  Whether  pedunculated  or  not,  the 
overgrowth  in  posterior  median  hypertrophy  projects  backward  and 
upward,  producing  serious  mechanical  disturbances  at  the  neck  of 
the  bladder. 

Some  theorizing  has  been  done  upon  the  causes  of  the  transforma- 
tion of  posterior  median  overgrowths  into  polyx^oid  tumors.  It  has 
been  asserted  that  the  mechanical  squeezing  to  which  the  part  is  sub- 
jected during  frequent,  painful,  and  more  or  less  spasmodic  efforts  at 
micturition  is  responsible  for  the  jutting  out  and  eventual  peduncula- 
tion  of  the  growth.  It  seems  reasonable  to  suppose  that  in  certain 
instances  such  an  explanation  is  logical,  especially  where  the  point  of 
departure  of  hypertrophy  is  thoroughly  circumscribed  in  the  posterior 
median  portion  of  the  organ. 

The  term  median  lobe  is  an  unfortunate  one,  as  it  is  apt  to  lead  to 


HYPEETROPHY  OP  THE  PROSTATE.  409 

the  supposition  that  a  third  or  middle  lobe  exists  in  the  normal  pros- 
tate, when,  as  a  matter  of  fact,  the  projecting  growth  is  invariably  a 
pathological  formation,  being  due  primarily  in  all  probability  to  a 
peculiar  circumscribed  hyperplasia  of  that  jDortion  of  the  organ  con- 
stituting the  posterior  portion  of  the  floor  of  the  prostatic  urethra. 
This  portion  of  the  organ  is  quite  important  in  its  relations  to  the 
sexual  function,  and  it  is  j)ossible  that  the  frequent  limitation  of 
prostatic  hyjiertrophy  to  this  region  is  a  point  in  evidence  of  the 
causal  relation  of  aberrations  of  sexual  physiology  to  the  disease. 
In  a  general  way,  whatever  the  form  of  hypertrophy  may  be,  it  pro- 
duces its  most  serious  effects  by  mechanically  obstructing  the  outflow 
of  urine.  Marked  secondary  changes  in  the  floor  of  the  bladder  are 
chiefly  dependent  upon  this  mechanical  obstruction.  The  pouching 
of  the  vesical  walls  in  the  vicinity  of  the  trigone,  known  as  the  has  fond 
or  lower  bottom,  depends  for  its  formation  chiefly  upon  the  intravesi- 
cal pressure  incidental  to  mechanical  obstruction  of  the  vesical  neck. 

As  classified  by  Thompson,  there  are  four  varieties  of  hypertrophy 
according  to  the  relative  degree  of  involvement  of  the  several  struc- 
tures of  which  the  prostate  is  composed,  ^dz. :  (1)  Simple  increase 
in  the  development  of  all  the  component  tissues  of  the  organ  in  about 
equal  ratio.  (2)  Excess  of  development  of  the  stromatous  and  fibrous 
structures — i.e.,  pale  muscular  fibre,  connective  tissue  and  elastic  tis- 
sue— over  the  glandular  portion.  (3)  Excess  of  development  in  the 
glandular  portion — i.e.,  basement  membrane,  follicles,  excretory 
ducts,  and  epithelium — over  the  stromatous.  (4)  Rearrangement  of 
the  structures,  stromatous  and  glandular,  in  the  form  of  a  tumor — cir- 
cumscribed or  localized  development.  Of  these  varieties  the  second  or 
stromatous  variety  is  the  most  frequent.  It  is  stated  by  Thompson 
that  of  70  specimens  of  hypertrophied  prostate  in  the  Museum  of  the 
Eoyal  College  of  Surgeons,  in  17  there  were  isolated  tumors  which 
were  clearly  discernible.  These  tumors  he  divides  into  (1)  those 
embedded  in  the  substance  of  the  organ,  but  the  structure  of  which 
is  isolated  from  that  surrounding  them,  and  (2)  outgrowths  or 
tumors  which  are  continuous  in  structure  with  the  portion  of  the 
prostate  from  which  they  spring,  but  which  manifest  a  tendency  to 
become  partially  isolated  by  assuming  a  more  or  less  polypoid  form 
and  maintaining  attachment  to  the  parent  body  through  the  medium 
of  a  pedicle  only. 

Some  cases  of  isolated  tumor  approximate  very  closely  in  their 
structure,  myo-fibroma.  Indeed,  Rokitansky  formerly  considered 
these  tumors  to  be  simple  fibrous  formations  similar  to  fibroids  oc- 
curring in  other  portions  of  the  body.  Upon  careful  examination 
they   are    usually — according    to   some  authorities,    always — found 


410  LTDSTON — DISEASES   OP  THE  PROSTATE, 

to  be  of  a  structure  quite  similar  to  that  of  the  remainder  of  the 
organ,  i.e.,  of  a  fibro-adenomatous  character  with  but  little  muscular 
tissue.  They  may,  however,  be  completely  isolated  by  a  true  fibrous 
capsule  from  which  they  may  be  readily  shelled  out.  It  is  not  un- 
usual to  find  circumscribed  posterior  median  growths  which  are  cov- 
ered apparently  only  by  vesical  mucous  membrane,  and  which  are 
readily  shelled  out  with  the  finger  after  incision  of  the  overlying 
tissues.  In  a  recent  operation,  the  author  removed  a  growth  of  this 
kind  with  the  index  finger  with  very  little  force  and  without  any  pre- 
liminary cutting  whatever.  These  growths  resemble  adenoma  rather 
than  fibro-myoma. 

Bar  at  the  Vesical  Neck. — There  occurs  in  some  cases,  as  a  conse- 
quence of  hypertrophy  of  the  prostate,  what  was  called  by  Guthrie 
"bar  at  the  neck  of  the  bladder."  The  classical  form  may  occur  in- 
dependently of  prostatic  hypertrophy,  from  enlargement  of  the  mus- 
cular fibres  which  run  across  the  trigonum  vesicae  just  behind  the 
prostate.  As  a  consequence  of  this  enlargement  the  bundle  of  mus- 
cular fibres  projects  from  the  floor  of  the  bladder  so  as  to  produce 
decided  obstruction  to  the  flow  of  urine.  Prostatic  hypertrophy 
proper  produces  bar  at  the  neck  of  the  bladder  in  two  ways.  In 
the  first  instance,  the  hypertrophy  of  the  prostatic  tissue  is  circum- 
scribed, runs  transversely  across  the  floor  of  the  prostatic  sinus,  and 
does  not  form  a  definite  tumor.  The  other  method  of  formation  is 
by  the  projection  of  two  portions  (lobes)  of  the  hypertrophied  pros- 
tate, in  such  a  manner  that  the  mucous  membrane  is  stretched  across 
the  neck  of  the  bladder  between  them.  In  some  cases  the  bar  is 
seemingly  due  to  a  general  atheroma  of  the  bladder  and  is  associated 
with  columnar  formation  of  hyperplastic  tissue  in  the  course  of  the 
ureters.  The  author  has  seen  one  specimen  of  bar  in  a  subject  thirty- 
two  years  of  age. 

Dimensions. 

The  size  of  the  hypertrophied  prostate  varies  considerably. 
Thompson  records  a  case  in  which  the  transverse  diameter  exceeded 
four  and  one-half  inches,  the  weight  of  this  tumor  being  about  twelve 
ounces.  He  says,  however,  that  such  a  size  is  rarely  attained, 
although  a  diameter  of  three  inches  is  not  uncommon.  As  a  rule 
the  enlargement  is  rather  moderate.  Considerable  enlargement  may 
exist,  if  the  organ  be  uniformly  involved,  without  producing  any 
very  marked  symptoms.  A  relatively  small  enlargement  of  the  so- 
called  median  lobe  is,  however,  sufficient  to  produce  considerable 
annoyance. 


hypeetkophy  of  the  prostate.  411 

Frequency. 

According  to  Thompson,  it  lias  been  found  that  (1)  "  enlargement 
of  the  prostate  in  a  moderate  degree  occurs  in  one  out  of  every  three 
individuals  at  middle  age.*  (2)  Thirty  per  cent  of  men  above  fifty 
years  of  age  have  '  fibrous  tumors'  of  the  prostate.  (3)  After  the  age 
of  fifty  one  man  in  every  eight  has  marked  enlargement,  but  excep- 
tionally before  the  age  of  sixty ;  (4)  The  disease  rarely  begins  later 
than  seventy  years  of  age." 

Morbid  Anatomy. 

On  dissection  the  hypertrophied  prostate  is  usually  found  to  be 
hard  and  indurated  as  compared  with  the  normal  consistency  of  the 
organ.  Sometimes,  on  the  other  hand,  although  considerably  en- 
larged, its  texture  is  comparatively  soft  and  loose.  This  is  usually, 
however,  in  the  early  cases.  The  more  indurated  variety  is  often 
associated  with  atheroma.  The  varying  forms  of  hypertrophy  have 
already  been  noted.  The  most  frequent  variety  of  enlargement,  from 
an  anatomical  standpoint,  is  that  in  which  the  structure  is  uniformly 
involved.  Clinically,  however,  median  hypertrophy  is  the  most  fre- 
quently met  with  because  of  its  invariably  disagreeable  results.  In- 
dividuals with  a  moderate  amount  of  general  enlargement  of  the 
prostate  may  live  to  an  advanced  age,  without  ever  experiencing 
sufficient  discomfort  to  compel  them  to  seek  the  aid  of  the  surgeon. 
As  a  corollary,  it  is  obvious  that  in  the  majority  of  cases  which  pre- 
sent themselves  to  our  observation,  we  are  justified  in  assuming  that 
median  hypertrophy  exists.  The  three  pathological  divisions  of  the 
prostate,  i.e.,  the  median  and  two  lateral  lobes,  may  be  so  greatly 
enlarged  as  to  form  three  tolerably  distinct  tumors  jutting  out  from 
the  main  body  of  the  prostate ;  this  condition  of  affairs  is  very  apt  to 
be  associated  with  bar  at  the  neck  of  the  bladder.  As  a  consequence 
of  the  enlargement  of  the  organ  the  prostatic  urethra  is  increased  in 
length,  and  its  curve  is  exaggerated.  If  the  enlargement  is  at  all 
irregular  or  asymmetrical  the  canal  is  tortuous.  The  elasticity  of  the 
prostatic  urethra  is  necessarily  impaired  in  all  cases.  The  increased 
length  of  the  urethra  is  a  most  important  consideration  in  the  sur- 
gery of  the  part,  inasmuch  as  it  becomes  necessary  to  adapt  the 
curve  and  the  method  of  introduction  of  the  instruments  necessary 
for  treatment  to  the  abnormal  form  of  the  canal.  On  section  the 
organ  is  usually  found  to  be  quite  hard,  pale,  and  comparatively 

*  Reginald  Harrison  also  states,  that  one-third  of  the  male  population  of  the 
■world  who  have  passed  the  age  of  fifty-five  years  are  the  subjects  of  prostatic  hy- 
pertrophy. 


412  LYDSTON — DISEASES   OF  THE   PROSTATE. 

bloodless.  There  is  in  most  cases  an  evident  increase  of  all  of  the 
elements  of  the  organ,  more  especially  of  the  muscular  and  fibrous 
stroma.  This  hyperplasia  is,  in  the  opinion  of  the  author,  the  most 
important  factor  of  the  disease.  As  akeady  stated,  isolated  tumors, 
simulating  myomata  (?)  or  fibro-adenomata,  may  be  found,  in  some 
cases  surrounded  by  a  distinct  capsule,  and  in  others  not  so  readily 
outlined.  Prostatic  concretions  may  be  found  in  some  instances,  and  if 
numerous  they  may  be  contained  in  a  sort  of  sac  produced  by  ab- 
sorption of  the  tissue  of  the  prostate,  incidental  to  the  pressure  of 
the  calculi.  These  calculi  may  be  found  outside  the  prostate  proper, 
in  the  glandular  tissue  about  the  vesical  neck. 

The  floor  of  the  bladder  behind  the  j^rostate  is  dilated,  often 
thinned,  sometimes  thickened  by  atheroma  forming  the  depression 
already  alluded  to  as  the  has  fond  or  lower  bottom.  This  is  found  in 
advanced  cases  to  contain  more  or  less  fetid  and  ammoniacal  urine 
mixed  with  mucus,  pus,  and  triple  phosphate.  In  many  instances 
a  definite  calculus  is  found.  The  occurrence  of  phosphatic  calculi  in 
cases  of  prostatic  disease  is  verj^  readily  explained:  As  a  conse- 
quence of  decomposition  of  the  residual  urine,  more  or  less  phosphatic 
material  is  formed ;  this  deposits  upon  a  mass  of  muco-pus  secreted 
by  the  inflamed  bladder  or  upon  a  blood  clot,  and  solidifies,  the  pro- 
cess being  precisely  similar  to  the  crystallization  of  sugar.  When 
once  a  small  calculus  has  formed  it  grows  with  considerable  rapidity ; 
it  enhances  the  inflammation,  increases  the  secretion  of  muco-pus 
and  deposition  of  phosphates,  and  enlarges  very  much  after  the 
fashion  of  a  rolling  snowball,  layer  after  layer  of  phosphatic  mate- 
rial being  deposited  upon  its  surface  until  finally  in  some  instances 
an  almost  incredible  size  is  attained.  The  nucleus  may  be  formed 
by  insoluble  drugs  or  foreign  bodies  introduced  into  the  bladder,  or 
may  consist  of  uric  acid  or  urates.  The  tyi)ical  calculus  of  ilnQ  prosta- 
tique,  however,  is  phosphatic.  The  bladder,  as  a  consequence  of 
obstruction  to  the  urinary  outflow,  undergoes  compensatory  hyper- 
trophy, and  eventually  its  mucous  membrane  becomes  inflamed  and 
presents  the  ordinary  appearances  of  chronic  cystitis. 

The  associated  pathological  conditions  of  that  portion  of  the 
genito-urinary  tract  above  the  prostate  naturally  call  for  considera- 
tion under  the  head  of  the  morbid  anatomy  of  prostatic  hypertrophy. 
It  will  be  understood  that  these  conditions  are  mainly  secondary  to 
the  prostatic  hypertrophy,  varying  in  degree  according  to  the  variety 
and  extent  of  the  obstruction  and  dependent  more  particularly  upon 
the  presence  or  absence  as  well  as  the  duration  and  severity  of  infec- 
tion, secondary  to  the  urinary  obstruction.  The  mechanical  disturb- 
ance produces  in  the  first  instance  serious  obstruction  to  the  return 


HYPEETROPHY  OF  THE  PEOSTATE.  413 

flow  of  blood  through  the  veins.  Vesical  hyperplasia  and  congestion 
of  the  mucous  membrane  with  resultant  excessive  formation  of  mucus 
is  a  natural  result.  In  some  instances  the  bladder  becomes  enor- 
mously thickened  as  a  consequence  of  the  frequent  and  forcible  efforts 
at  micturition.  Interstitial  proliferation  of  connective  tissue  occurs, 
and  the  bladder  finally  contracts  down  into  a  hard  mass  little  resem- 
bling the  normal  viscus,  the  ca^dty  of  which  may  contain  but  a  few 
drachms  of  urine.  In  other  instances,  as  a  consequence  of  attacks  of 
retention  from  time  to  time  superadded  to  the  continual  obstruction 
to  the  urinary  outflow,  the  bladder  becomes  atonic,  dilated,  and  pre- 
sents a  trabeculated  appearance  incidental  to  the  hypertrophy  of 
the  fasciculi  of  muscular  fibres  composing  its  walls.  The  portions  of 
the  bladder  walls  corresponding  to  the  interstices  between  these  bun- 
dles of  muscular  fibres  are  relatively  thinned,  dilated,  and  perhaps 
sacculated,  the  sacculi  containing  decomposing  urine,  muco-pus, 
phosphates,  and  perhaps  one  or  more  calculi,  presenting  in  short  the 
same  conditions  as  does  the  bas  fond  in  the  presence  of  a  septic 
cystitis.  The  mechanical  effect  of  the  prostatic  hypertrophy  extends 
further  than  the  bladder  and  involves  the  ureters  and  kidneys. 
These  may  be  dilated  and  thickened.  The  kidney  presents  more  or 
less  thinning  of  its  cortex  with  dilatation  of  its  pelvis.  These  results 
occur  sooner  or  later  whether  or  not  infection  of  the  bladder  is 
superadded.  The  disturbance  of  nutrition  incidental  to  this  condi- 
tion of  dilatation  and  thinning  from  the  backward  pressure  of  the 
urine  affords  a  locus  minoris  resistentice  which  is  extremely  favotable 
to  bacterial  infection.  The  slightest  degree  of  hypergemia  super- 
added to  this  condition  may  completely  suspend  the  already  more  or 
less  inhibited  function  of  renal  secretion  with  resulting  uraemia  and 
speedy  death.  Necessarily  the  impairment  of  function  incidental 
to  the  chronic  conditions  produced  by  the  urinary  obstruction  results 
in  a  greater  or  less  degree  of  urinary  empoisonment  of  the  general 
system.  The  septic  effects  of  prostatic  hypertrophy  are  attributable 
directly  or  indirectly  to  bacterial  infection.  The  congested  hyper- 
secreting  mucous  membrane  of  the  bladder  affords  a  favorable  soil  for 
bacterial  infection ;  the  mucus  secreted  favors  chemical  changes  in  the 
urine.  The  collection  of  residual  urine  in  the  has  fond  behind  the 
obstruction  is  more  or  less  stagnant  as  a  consequence  of  imperfect 
emptying  of  the  bladder  and  very  readily  undergoes  decomposition 
under  favorable  circumstances  of  bacterial  infection.  The  condi- 
tions necessary  for  infection  are  almost  invariably  afforded  by  septic 
catheterization  by  either  the  patient  or  his  physician.  Consequent 
upon  the  sepsis,  cystitis  with  ammoniacal  decomposition  of  urine 
results.     The  infection  in  extreme  cases  travels  along  the  ureter  to 


414  LXDSTON — DISEASES  OF  THE  PKOSTATE. 

the  kidney,  setting  up  septic  pyelitis  and  finally  pyelonepliritis.  The 
process  develops  so  gradually  that  the  patient  may  tolerate  it  for  a 
prolonged  period.  In  some  instances  the  urine  when  freed  from  the 
products  of  mucous  inflammation  appears  so  nearly  normal  that 
serious  renal  disease  is  not  suspected.  The  degree  of  involvement  of 
the  kidney  compatible  with  life  is,  in  these  cases,  something  ex- 
traordinary. The  patient  may  tolerate  his  pyelonephritis  for  a  pro- 
longed period  and  may  appear  to  be  a  favorable  subject  for  opera- 
tion. Operative  shock  and  ansesthesia,  however,  precipitate  acute 
hypersemia  of  the  ah^eady  damaged  kidney,  and  the  patient  dies,  the 
post-mortem  examination  revealing  the  fact  that  but  a  very  small  pro- 
portion of  cortical  substance  of  the  kidney  remains,  and  this  is  so 
damaged  that  it  is  extraordinary  that  the  patient  should  have  been 
able  to  endure  it  for  so  long  a  time.  The  gradual  development  of  the 
process,  with  a  relatively  slow  tissue  metabolism  and  a  certain  degree 
of  acc[uired  tolerance  of  urinary  toxsemia  is  the  probable  explanation. 
The  practical  point  which  the  author  desires  to  emphasize  is  that  seri- 
ous impairment  of  the  kidneys  is  inevitable  in  all  cases  of  prostatic 
hypertrophy  which  produces  even  moderately  serious  obstruction  to 
the  urinary  outflow,  if  the  obstruction  be  allowed  to  continue  for  any 
great  length  of  time.  In  long-standing  cases  in  which  operation  is 
proposed,  the  existence  of  serious  impairment  of  the  structure  and 
function  of  the  kidneys  is  to  be  taken  for  granted,  the  condition  of 
the  urine  to  the  contrary  notwithstanding. 

Symptoms. 

The  symptoms  of  prostatic  hypertrophy  are  obviously  those  inci- 
dental to  urinary  obstruction  and  the  various  conditions  secondary 
to,  or  engrafted  upon  it  by,  infection.  Hypertrophy  must  neces- 
sarily exisfc  in  many  instances  for  a  long  time  before  symptoms  are 
produced.  The  condition  is  not  painful  per  se,  and  there  may  be  no 
evidence  of  its  existence  until  a  sufficient  size  has  been  attained  to 
produce  mechanical  interference  with  the  function  of  urination.  In 
quite  a  proportion  of  cases,  however,  more  or  less  marked  symptoms, 
referable  to  the  vesical  neck,  exist  for  some  years  before  any  appre- 
ciable degree  of  obstruction  occurs. 

As  the  prostate  is  one  of  the  principal  factors  in  the  coup  de 
piston,  or  the  flnal  spasmodic  contraction  of  the  urethral  and  cut-off 
muscles  for  the  purpose  of  ejaculating  the  final  drops  of  urine  or 
semen  from  the  urethra,  one  of  the  first  symptoms  of  prostatic  hyper- 
trophy is  difficulty  in  clearing  the  canal  of  fluid.  Obviously,  whether 
the  prostate  is  an  active  participant  in  the  process  of  closing  the  neck 


HYPERTEOPHY  OP   THE  PROSTATE.  415 

of  the  bladder  at  the  termination  of  urination  or  not,  it  must  neces- 
sarily interfere  with  this  process  when  it  becomes  rigid  and  enlarged, 
by  resisting  the  pressure  of  the  cut-off  muscle.  The  individual  soon 
notices  a  little  tardiness  in  the  commencement  of  the  flow  and  a  lack 
of  force  of  the  stream  of  urine.  The  explanation  of  this  is  very  sim- 
ple. Under  normal  conditions  there  is  nothing  to  retard  the  flow  of 
urine  after  the  cut-off  muscle  has  been  voluntarily  relaxed,  the  pros- 
tate being  elastic  and  distensible.  When,  however,  it  has  become 
rigid  and  inelastic  it  opposes  the  action  of  the  detrusor  urinse  muscle 
and  inhibits  in  a  certain  degree  the  flow  of  urine.  This  is  in  itself 
sufficient  to  induce  sooner  or  later  compensatory  hypertrophy  of  the 
vesical  walls.  The  stream  of  urine  may  be  a  trifle  smaller  than  nor- 
mal, but,  as  a  rule,  it  is  not  appreciably  changed,  a  very  important 
point  in  differentiating  this  condition  from  stricture  of  the  urethra. 
Pouching  of  the  bladder  at  the  has  fond  occurs  in  many  cases  before 
appreciable  symptoms  are  manifest,  and  as  a  consequence  the  bladder 
is  never  entirely  empty,  a  few  drops  of  urine  accumulating  in  this 
situation  quite  early  in  the  course  of  the  case.  If  bacteria  enter  the 
bladder  this  residuum  decomposes  and  produces  irritation  and  a  conse- 
quent catarrhal  condition  of  the  vesical  mucous  membrane,  with  a 
resultant  feeling  that  the  bladder  has  not  been  entirely  emptied.  The 
author  desires  to  emphasize  the  fact  that  it  is  not  the  residual  urine 
per  se  that  produces  the  irritation;  it  is  tolerated  unless  infected.  As 
the  case  goes  on  the  calls  to  micturate  become  more  frequent.  A 
sense  of  fulness  and  discomfort  in  the  perineum  and  rectum  are  ex- 
perienced after  a  time,  this  symptom  being  aggravated  during  and 
after  stool,  particularly  if  the  bowels  be  constipated.  There  may  be 
so  much  irritation  about  the  parts  that  the  nerves  of  sexual  sensi- 
bility are  affected  with  the  production  of  priapism.  Instances  of 
extreme  libidinousness  in  old  men  are  usually  associated  with  hyper- 
trophy of  the  prostate.     In  other  cases  impotence  results. 

As  the  case  progresses  the  cystitis  becomes  more  marked,  the  has 
fond  increases  in  depth  with  a  consequent  increase  in  the  amount  of 
residual  urine,  and  the  obstruction  at  the  neck  of  the  bladder  be- 
comes so  marked  that  the  organ  contains  quite  a  quantity  of  urine 
after  the  patient  has  apparently  emptied  it.  It  is  sometimes  a  mat- 
ter of  surprise  to  the  patient,  especially  if  he  consults  a  surgeon  early 
in  the  course  of  the  case,  to  find  that  it  is  possible  to  draw  off  a  large 
quantity  of  urine  with  the  catheter  when  he  supposes  that  he  has 
emptied  the  bladder  completely. 

Incontinence  of  urine,  especially  at  night,  is  a  frequent  symptom. 
It  is  due  to  overflow  of  the  distended  bladder  at  a  time  when  the 
tonicity  of  the  cut-off  muscle  is  interfered  with.    The  normal  tonicity 


416  LYDSTON — DISEASES  OF  THE  PEOSTATE. 

of  this  complex  muscle,  in  combination  with  the  volitional  power  of 
the  patient,  is  sufficient  to  prevent  dribbling  of  virine  (excepting  after 
prolonged  retention)  in  the  day-time.  When,  however,  the  volition 
is  inhibited  by  sleep,  overflow  is  quite  apt  to  occur.  Another  cause 
for  apparent  incontinence  at  night  is  a  reflex  effort  on  the  part  of  the 
bladder  to  empty  itself  under  the  stimulus  of  inflammation  about 
the  vesical  neck.  A  point  which  has  hardly  received  sufficient  atten- 
tion is  the  fact  that  when  the  prostate  is  uniformly  enlarged  the  neck 
of  the  bladder  loses  its  contractility,  and  is  rendered  more  patulous 
than  usual,  although  it  may  be  apparently  contracted  on  account  of  the 
loss  of  elasticity.  The  condition  is  yqyj  much  like  that  which  would 
occur  from  the  substitution  of  a  small  but  rigid  and  inelastic  tube  for 
a  comparatively  large,  elastic,  and  contractile  one.  Attacks  of  com- 
plete retention  eventually  occur  from  time  to  time ;  these  are  usually 
superinduced  by  acute  congestion  of  the  prostate  and  vesical  neck, 
incidental  to  excesses  in  eating,  drinking,  sexual  indulgence,  or  to 
exposure  to  wet  and  cold,  particularly  under  circumstances  favoring 
chilling  of  the  lower  extremities.  The  pain  and  prostration  due  to  re- 
tention are  apt  to  be  entirely  disproportionate  to  the  amount  of  urine 
contained  in  the  bladder;  some  patients  will  suffer  severely  from  the 
retention  of  a  comparatively  small  quantity  of  urine,  while  others  will 
passively  permit  the  bladder  to  become  enormously  distended  with- 
out sending  for  aid.  The  author  recalls  a  case  which  was  quite  inter- 
esting as  bearing  upon  this  point.  This  patient  was  an  old  gentleman 
of  seventy -five  years  of  age  who  had  suffered  for  years  from  enlarge- 
ment of  the  prostate  with  occasional  attacks  of  retention.  On  this 
occasion,  as  a  consequence  of  slight  exposure,  he  found  himself 
unable  to  pass  water,  the  retention  being  associated  with  the  most 
severe  pain  and  vesical  tenesmus.  He  was  in  a  condition  of  extreme 
prostration  as  a  consequence  of  his  suffering,  but  stated  that  he 
had  been  able  to  i^ass  urine  four  or  five  hours  previously.  The 
catheter  showed  that  the  bladder  did  not  contain  more  than  a  pint 
and  a  half  of  urine  of  a  comparatively  healthy  appearance.  Cases  of 
this  kind  are  due  to  acute  hypersemia  of  the  prostate  and  vesical 
neck,  causing  these  parts  to  become  extremely  hypersesthetic.  It  is 
to  be  remembered  in  this  connection  that  cases  occasionally  arise  in 
which  the  bladder  becomes  immensely  hypertrophied  and  contracted, 
so  that  it  will  contain  but  a  few  drachms  of  urine.  Such  cases,  how- 
ever, do  not  present  the  clinical  features  of  the  case  in  question,  in 
which  the  bladder  was  very  tolerant  of  urine  as  long  as  it  was  evacu- 
ated and  the  mucous  membrane  irrigated  at  proper  intervals. 

Urethral  fiuses  of  muco-pus  are  occasionally  seen  in  cases  of  en- 
larged prostate.     These  are  due  either  to  mechanical  pressure  on  the 


HYPERTROPHY  OF  THE   PROSTATE.  417 

organ  during  stool  or  micturition  or  to  coexisting  anterior  urethritis. 
In  long-standing  cases  tliere  may  be  from  time  to  time  urethral 
hemorrhage  as  a  consequence  of  prostatic  congestion.  These  cases 
are  less  liable  to  acute  retention  because  of  the  conservative  effect  of 
the  bleeding. 

As  the  morbid  changes  increase,  the  patient  becomes  very  irrita- 
ble and  testy ;  slight  chilly  sensations  and  more  or  less  fever,  partic- 
ularly during  the  afternoon,  are  not  unusual.  The  functions  of  the 
digestive  organs  are  apt  to  be  more  or  less  disturbed ;  the  general 
strength  is  somewhat  impaired,  sometimes  early  in  the  case.  These 
various  symptoms  are  due  to  more  or  less  impairment  of  the  function 
of  the  kidneys  with  consequent  slight  uraemia,  in  combination  with  a 
certain  degree  of  absorption  of  the  products  of  decomposition  from 
the  urinary  tract.  This  condition  may  be  termed  chronic  urinary 
fever. 

In  the  early  stages  of  enlarged  prostate  the  urine  contains  more 
or  less  mucus ;  later  on  this  is  replaced  by  muco-pus  in  the  form  of 
little  masses  and  clots,  and  an  abundance  of  triple  phosphates.  Some- 
times the  fluid  is  dark  from  admixture  with  blood,  particularly  if 
calculus  exists.  The  acidity  of  the  urine  gradually  diminishes  until 
it  eventually  becomes  very  ammoniacal  and  fetid. 

If  calculus  forms  in  the  course  of  the  case  there  may  be  consider- 
able pain,  especially  during  movements  involving  jolting  of  the 
body,  but  this  pain  is  not  so  marked  as  in  cases  of  calculus  dependent 
upon  other  causes.  In  ordinary  cases  of  stone  the  stream  of  urine 
during  micturition  is  apt  to  be  suddenly  checked,  and  coincidentally 
severe  pain  with  more  or  less  bleeding  occurs  during  the  expulsion  of 
the  last  few  drops  of  urine.  In  enlargement  of  the  prostate  the  stone 
lies  passively  behind  the  obstruction  at  the  neck  of  the  bladder,  and 
as  the  contractility  of  the  muscular  walls  of  the  has  fond  is  impaired 
it  is  not  impelled  against  the  sensitive  vesical  neck  at  the  termination 
of  micturition. 

Attacks  of  acute  cystitis  may  occur  from  time  to  time  in  the  course 
of  hypertrophy  of  the  prostate,  and  are  apt  to  lead  to  a  fatal  result 
through  exhaustion  or  perhaps  gangrene  of  the  vesical  mucous  mem- 
brane. Patients  of  a  gouty  or  rheumatic  diathesis  are  particularly 
apt  to  have  intercurrent  attacks  of  retention  and  acute  inflammation. 

As  the  foregoing  symptomatology  demonstrates,  there  is  no  class 
of  patients  who  are  more  worthy  of  the  sympathy  and  careful  atten- 
tion of  the  x^hynician  than  the  unfortunate  victims  of  pronounced 
prostatic  hyx)ertrophy.  It  is  indeed  sad  that  such  a  large  profjortion 
of  humanity  should  be  afflicted  with  so  harassing  an  affection  during 
the  declining  years  of  life,  at  a  time  when  there  are  so  many  other 
Vol.  I.— 27 


418  LYDSTON — DISEASES   OF   THE   PROSTATE. 

infirmities  incidental  to  senility  to  render  tlie  life  of  tlie  old  man  un- 
comfortable. As  a  consequence  of  tlie  drain  upon  the  system  pro- 
duced by  tlie  discharge  of  pus  from  the  bladder  and  depression  of 
the  nervous  system  from  pain  and  loss  of  sleep  in  combination  with 
the  effects  of  general  senile  decline,  the  patient  with  enlarged  prostate 
is,  apt  to  have  his  life  considerably  shortened,  even  if  he  escapes  the 
dangers  of  acute  retention,  cystitis,  and  renal  complications.  The 
fact  that  the  life  of  the  patient  will  inevitably  be  made  miserable  is 
sufficient  to  warrant  us  in  seeking  radical  measures  of  relief  and 
adopting  them  at  an  early  period  when  operation  is  comparatively 
safe  and  holds  out  a  reasonable  prospect  for  permanent  benefit. 

Diagnosis. 

The  most  accurate  information  regarding  the  condition  of  the 
prostate  body  is  to  be  obtained  by  rectal  exploration  with  the  finger. 
The  bowels  should  be  evacuated  by  means  of  an  enema,  and  if  the 
patient  is  very  sensitive  a  small  quantity  of  morphine  or  cocaine  may 
be  introduced  by  suppository  a  short  time  previous  to  the  examina- 
tion. The  prostate  is  discernible  to  the  expert  finger  even  in  its  nor- 
mal condition,  but  whenever  it  is  at  all  prominent  some  condition  of 
disease  may  be  inferred.  In  certain  cases  of  enormous  enlargement 
of  the  organ  the  rectum  is  so  encroached  upon  that  the  tumor  can  be 
felt  immediately  the  finger  passes  the  sphincter,  rendering  it  neces- 
sary to  depress  the  finger  in  order  to  pass  it  by  the  obstruction.  By 
this  mean  of  exploration  the  size  and  conformation  of  the  prostate  are 
very  readily  made  out.  When  the  median  lobe  is  enlarged  a  certain 
degree  of  resistant  fulness  will  be  detected  above  the  upper  border 
of  the  body  of  the  organ  at  a  point  where,  when  the  prostate  is  nor- 
mal, nothing  can  be  felt,  excepting  the  elastic  fluctuating  wall  of  the 
bladder.  It  is  desirable  to  note  whether  the  bladder  is  accessible 
beyond  the  border  of  the  prostate  as  evidenced  by  marked  fluctua- 
tion, especially  if  there  exists  the  possible  necessity  of  tapping  the 
bladder  through  the  rectum.  If  there  is  much  inflammation  or  acute 
hypergemia,  the  finger  elicits  great  tenderness  with  rectal  and  vesical 
tenesmus.  Any  irregularities  of  the  prostate  which  may  possibly 
indicate  tumorous  outgrowths  should  be  carefully  outlined  and  noted. 

Great  assistance  in  exploration  is  afforded  by  a  metallic  catheter 
introduced  into  the  bladder.  The  instrument  and  the  exploring  fin- 
ger in  the  rectum  are  made  to  engage  between  them  the  structures 
about  the  neck  of  the  bladder.  In  this  way  a  very  fair  approximate 
idea  of  the  extent  of  the  hypertrophy  and  the  degree  of  induration 
may  be  formed.     By  urethral  exploration  we  may  often  derive  con- 


HYPERTROPHY   OF   THE   PROSTATE.  419 

siderable  information  regarding  tlie  condition  of  the  prostate.  In 
a  suspected  case  of  hypertrophy  the  first  attempt  at  exploration 
should  be  made  with  an  ordinary  catheter.  If  this  passes  readily 
without  the  necessity  of  marked  depression  of  its  handle,  and  if,  more- 
over, urine  flows  through  it  when  it  has  penetrated  to  the  depth  of 
seven  or  eight  inches,  the  prostate  is  in  all  probability  not  apprecia- 
bly enlarged.  If,  on  the  other  hand,  hypertrophy  exists  it  will  be 
found  necessary  to  depress  the  handle  of  the  catheter  well  downward 
toward  the  feet  of  the  patient  before  its  point  will  enter  the  bladder, 
and  even  then  it  may  be  found  impossible  to  introduce  it  without  the 
use  of  undue  force,  because  of  the  point  impinging  upon  the  bar  at 
the  vesical  neck  or  the  median  lobe,  as  the  case  may  be.  If  we  suc- 
ceed in  entering  the  bladder  the  urine  often  does  not  flow  until  the  in- 
strument has  penetrated  to  a  depth  of  say  ten  inches  or  more.  If  the 
ordinary  catheter  does  not  readily  enter  the  bladder  Thompson's 
metallic  prostatic  catheter,  which  has  a  longer  and  greater  curve, 
should  be  employed.  If  median  hypertrophy  or  bar  exists  this  in- 
strument will  usually  pass  by  the  obstruction  with  comparatively 
little  difficulty.  When  the  lateral  lobes  are  asymmetrically  enlarged 
the  point  of  the  catheter  and  consequently  the  handle  are  deflected  in 
a  direction  corresponding  to  the  existing  malformation  of  the  urethra. 
The  depth  to  which  it  is  necessary  to  pass  an  instrument  before  the 
urine  flows  is  a  fair  criterion  of  the  degree  of  enlargement.  Thomp- 
son has  devised  a  "  searcher"  for  exploration  of  the  bladder,  which  in 
practised  hands  gives  very  valuable  information  regarding  the  size 
and  form  of  prostatic  hypertrophy,  the  presence  of  tumor  or  stone, 
and  the  depth  of  the  has  fond. 

It  will  be  found  best  in  the  majority  of  cases  to  examine  the 
patient  in  the  dorsal  decubitus  with  the  knees  and  thighs  flexed  and 
separated.  In  rectal  examination  of  the  prostate,  however,  the  writer 
has  found  a  posture  similar  to  the  Sims  gynecological  position  most 
favorable  to  exploration. 

The  differential  diagnosis  of  hypertrophy  of  the  prostate  requires 
the  exclusion  of  stricture,  vesical  calculus,  vesical  tumors,  atony, 
paralysis,  and  simple  catarrh  of  the  bladder — stricture  and  vesical 
calculus  being  the  diseases  for  which  it  is  most  likely  to  be  mistaken. 
Most  of  these  conditions  may  usually  be  excluded  by  a  careful  study 
of  the  history  of  the  case  and  physical  examination  of  the  size  and 
form  of  the  prostate  and  the  contour  and  length  of  the  urethra.  The 
age  of  the  patient  is  in  all  cases  a  most  important  consideration. 

It  is  wise  not  to  be  too  arbitrary  in  the  matter  of  diagnosis 
based  ui)on  subjective  symj^toms;  as  these  diseases  have  many  symp- 
toms in  common.     Very  often  a  calculus  will  coexist  with  enlarged 


420  LYDSTON — DISEASES  OF  THE  PROSTATE. 

prostate  and  be  unsuspected  because  of  the  fact  that,  as  already 
stated,  tlie  contractibility  of  tlie  vesical  walls  is  so  impaired  that  the 
stone  cannot  be  forced  against  the  tender  vesical  neck.  Rectal  ex- 
ploration and  the  passage  of  instruments  into  the  bladder  are  neces- 
sary to  complete  the  diagnosis  in  any  case. 

Treatment. 

Until  within  recent  years  the  treatment  of  hypertrophy  of  the 
prostate  embraced  only  measures  of  palliation.  Internal  medication 
and  treatment  by  pressure  in  the  hoi^e  of  absorbing  the  adventitious 
tissue  composing  the  overgrowth  had  alike  proven  ineffectual.  Rad- 
ical methods  of  surgical  relief  were  considered  inapplicable.  In  the 
minds  of  a  large  percentage  of  the  profession  this  same  view  holds  at 
the  present  day.  In  the  light  of  the  developments  of  modern  aseptic 
surgery,  however,  particularly  in  the  direction  of  operations  upon 
the  genito-urinary  tract,  this  old-time  view  should  be  abandoned. 
The  author  has  no  desire  to  foster  a  spirit  of  surgical  hyperacti\dty, 
but  he  is  firmly  convinced  that  there  is  a  wide  field  for  judicious 
operative  measures  in  the  treatment  of  hypertrophy  of  the  prostate. 
It  is  of  course  admitted  that  radical  measures  are  not  applicable  to  all 
cases,  but  it  is  also  claimed  that  the  results  of  operations  by  surgical 
routinists  should  by  no  means  be  taken  into  consideration.  In  cer- 
tain quarters  it  is  held  that  surgical  intervention  is  not  to  be  thought 
of  until  the  patient  is  in  such  a  desperately  bad  condition  that  oper- 
ative measures  afford  very  little  prospect  of  success.  The  surgery  of 
the  prostate  has  never  been  given  a  fair  opportunity  for  development. 
The  cases  which  are  submitted  for  operation  are  usually  those  in 
which  all  other  measures  of  treatment  have  not  only  failed  but  com- 
plicating conditions  have  arisen  which  seriously  enhance  the  dangers 
of  operation.  Operative  statistics  based  upon  the  results  obtained  in 
the  class  of  patients  upon  whom  we  at  present  have  the  most  frequent 
opportunities  of  operating  are  practically  worthless  excepting  in  so 
far  as  they  bear  upon  the  radical  cure  or  recovery  from  the  operation 
in  a  particular  class  of  desperate  cases.  "With  a  proper  understand- 
ing of  the  limitations  and  indications  of  the  operation  and  a  judicious 
selection  of  cases  there  is  no  reason  why  early  operations  upon  the 
prostate  should  not  yield  excellent  results.  In  the  opinion  of  the 
author,  radical  operations  upon  the  prostate  would  be  comparatively 
safe  if  performed  prior  to  the  development  of  septic  complications  or 
renal  disease — i.e.,  if  performed  at  a  comparatively  early  period  after 
the  development  of  the  urinary  obstruction.  A  fairly  good  prospect 
of  success,  sufficiently  good  to  warrant  operative  interference,  exists 


HYPERTROPHY  OF  THE  PROSTATE.  421 

even  after  vesical  complications  have  arisen,  providing  the  kid- 
neys have  retained  their  structural  and  functional  integrity.  Inas- 
much as  mechanical  obstruction  and  sepsis  sooner  or  later  cause 
serious  vesical  and  renal  conditions  in  by  far  the  majority  of  prosta- 
tiques,  it  is  evident  that  operation  should  be  done  much  earlier  than 
is  usual.  In  a  work  designed  for  medical  men  rather  than  surgeons 
elaborate  descriptions  of  operations  would  be  out  of  place.  Some 
general  considerations,  however,  may  be  of  value. 

From  an  operative  standpoint  cases  may  be  divided  for  consid- 
eration into : 

(a)  Incipient  cases  in  men  of  moderately  advanced  age  with  com- 
paratively healthy  bladder  and  kidneys. 

(b)  Advanced  cases  in  patients  of  otherwise  rugged  health  in 
whom  the  renal  function  appears  to  be  properly  performed,  the  blad- 
der not  being  seriously  involved,  but  in  whom  there  is  a  progressive 
increase  of  urinary  obstruction. 

(c)  Marked  cases  in  subjects  of  advanced  age  in  whom  serious 
renal  and  bladder  complications  exist,  but  in  whom  i)alliative  meas- 
ures are  successful. 

(d)  Advanced  cases  irrespective  of  the  age  of  the  patient  in  whom 
serious  complications  exist,  but  palliative  measures  are  of  no  avail. 

(e)  Cases  complicated  by  vesical  calculus. 

In  class  "  a"  we  have  to  deal  with  men  of  middle  age  or  beyond  it 
in  whom  symptoms  of  urinary  irritation  and  obstruction  have  just 
begun.  Measures  of  palliation,  with  strict  attention  to  the  rules  of 
genito-urinary  hygiene  and  the  occasional  passage  of  the  steel  sound, 
may  allay  the  irritability  of  the  vesical  neck  and  either  greatly  retard 
the  advance  of  the  hypertrophic  process  or  practically  prevent  it.  In 
some  instances  these  measures  of  palliation  are  so  signally  success- 
ful that  operation  is  not  to  be  thought  of.  Where  this  is  not  the 
case,  however,  or  where  after  moderately  successful  palliation  for  a 
period  of  months  or  years  the  urinary  obstruction  and  irritation  in- 
crease or  attacks  of  retention  come  on,  surgical  interference  is  justi- 
fiable and  should  be  performed  before  serious  vesical  and  renal  com- 
I)lications  have  time  to  develop,  and  while  the  constitution  of  the 
patient  remains  practically  unimpaired  by  vesical  irritation,  chronic 
urinary  fever,  loss  of  sleep,  etc. 

The  i)atients  included  in  class  "  V  are  naturally  the  legitimate 
successors  of  class  "a."     The  same  indications  for  operation  prevail. 

Class  "  c"  comprises  the  cases  par  excellence  in  which  nothing  but 
palliative  measures  should  be  considered.  Fortunately  the^^  comprise 
quite  a  i)roportion  of  cases  of  enlarged  prostate,  and  while  in  some  of 
them  ox)eration  might  have  been  justified  at  an  early  period,  it  cer- 


42^  LYDSTON— DISEASES  OF  THE  PROSTATE. 

tainly  is  not  so  at  a  more  advanced  period  of  life  as  long  as  measures 
of  palliation  keep  tlie  patient  perfectly  comfortable. 

In  class  "  c? "  are  embraced  patients  in  whom  the  only  liope  of 
prolongation  of  life  and  relief  of  symptoms  is  in  operative  measures, 
the  character  of  which  is  to  be  determined  largely  by  the  local  condi- 
tions found  at  the  time  of  operation. 

In  class  "  e"  there  is  to  the  mind  of  the  author  but  one  indication, 
viz.,  suprapubic  section  with  or  without  operation  upon  the  prostate 
proper,  and  invariably  with  prolonged  subsequent  drainage.  The 
question  of  operation  upon  these  patients  is  determined  by  the  exis- 
tence of  the  calculus,  but  modified  by  the  same  considerations  re- 
garding complications  and  the  strength  of  the  patient,  as  in  cases  in 
which  calculus  does  not  exist.  It  is  true  that  brilliant  results  are  re- 
ported from  the  operation  of  litholapaxy  in  prostatiques.  It  neverthe- 
less seems  to  the  author  less  rational  and  more  dangerous  upon  the 
average  than  suprapubic  section  and  drainage,  especiallj'  it  the  oper- 
ation be  done  in  two  stages. 

The  operative  measures  indicated  in  hypertrophy  of  the  prostate 
range  in  severity  from  simple  suprapubic  section  and  drainage  to 
removal  of  the  hypertrophic  tissue,  the  selection  of  operation  being 
dependent  upon  the  variety  of  hypertrophy  present,  the  condition  of 
the  bladder  and  kidneys,  and  the  degree  to  which  the  strength  of  the 
patient  has  been  undermined  by  the  disease.  Simple  suprapubic 
section  and  drainage  is  alone  to  be  thought  of  in  quite  a  proportion 
of  advanced  cases  with  serious  complications.  A  permanent  arti- 
ficial sjaprapubic  urethra  is  the  only  measure  of  relief  for  these  cases. 
The  anaesthesia  is  the  feature  of  the  operation  most  to  be  dreaded, 
and  where  practicable  it  is  advisable  to  perform  the  operation  in 
two  stages,  both  being  done  under  cocaine.  Should  distinctly  cir- 
cumscribed posterior  prostatic  tumors  exist  they  should  be  removed. 
For  this,  general  anaesthesia  is  required,  and  as  a  rule  chloroform 
is  the  anaesthetic  to  be  preferred.  It  is  sometimes  possible  to  remove 
a  pedunculated  growth  with  the  finger  alone.  In  these  advanced  cases, 
however,  it  is  advisable  not  to  perform  cutting  or  tearing  operations 
about  the  vesical  neck.  It  should  be  remembered  that  in  these 
cases  a  high  degree  of  vesical  sepsis  exists,  and  the  slightest  abrasion 
of  the  interior  of  the  bladder  is  quite  a  serious  matter.  In  some  in- 
stances it  is  advisable  to  defer  all  operative  measures  at  the  vesical 
neck,  either  permanently  or  until  such  time  as  the  bladder  and  gen- 
eral condition  of  the  patient  have  improved  under  the  influence  of 
vesical  drainage  and  irrigation.  Should  prostatotomy  or  prostatect- 
omy, however,  be  decided  on,  through-and-through  drainage  should 
be  instituted.     A  perineal  boutonniere   does   not  greatly  complicate 


HYPERTROPHY  OF  THE   PROSTATE.  423 

the  operation,  and  is  quickly  performed,  tlie  added  security  afforded 
tlie  patient  being  a  sufficient  warrant  for  its  performance.  In  younger 
subjects,  linear  prostatotomy,  or  prostatectomy  with  through-and- 
through  drainage  may  be  undertaken  with  a  much  better  prospect  of 
cure  than  in  the  cases  just  described. 

The  most  recent  operation  for  the  relief  of  enlarged  prostate,  cas- 
tration, seems  to  be  meeting  with  some  success.  The  author  has  had 
no  experience  with  it,  but  it  is  worth  consideration  providing  the  pa- 
tient's virility  has  disappeared,  otherwise  it  is  better  to  construct  an 
artificial  suprapubic  urethra,  with  or  without  operation  on  the  pros- 
tate proper.  Castration  is  an  operation  not  to  be  lightly  undertaken, 
as  certain  historical  medico-legal  cases  have  shown.  Should  future 
experience  demonstrate  that  it  is  frequently  successful,  the  surgeon 
should  still  exercise  the  greatest  circumspection  in  the  performance 
of  this  operation.  A  patient  who  appears  perfectly  reconciled  to  the 
loss  of  his  testes  may  subsequently  look  at  the  matter  in  a  different 
light.  There  is  a  suggestion  of  grim  humor  in  the  new  procedure; 
the  oophorectomy  craze  of  the  recent  past  is  still  a  vivid  recollection. 

The  indications  for  any  particular  operations  upon  the  prostate 
proper  are  governed  entirely  by  the  variety  and  form  of  the  pros- 
tatic hypertrophy^  It  is  obvious  that  in  quite  a  proportion  of  cases 
of  prostatic  hypertrophy,  the  treatment  must  devolve  upon  the  gen- 
eral practitioner  and  consist  of  measures  of  palliation.  The  author 
desires  to  impress  upon  the  practitioner,  however,  the  fact  that  the 
cases  in  which  palliative  measures  should  be  selected  and  relied  upon 
throughout  are  to  be  determined  only  by  careful  study.  Palliative 
treatment,  as  a  matter  of  routine,  should  no  longer  be  accepted  as  the 
inevitable  in  prostatic  hypertrophy,  excepting  under  circumstances 
in  which  it  is  impracticable  to  place  the  patient  under  suitable  con- 
ditions or  in  proper  hands  for  operative  measures.  The  palliative 
measures  of  treatment  necessarily  have  a  more  important  practical 
interest  to  the  general  practitioner  than  to  the  genito-urinary  spe- 
cialist. The  function  of  the  latter  is  often  that  of  a  consultant  only,' 
the  management  of  the  case,  if  operative  measures  are  not  advocated, 
being  subsequently  relegated  to  the  family  practitioner.  Compara- 
tively few  cases  of  such  prolonged  duration  as  are  those  of  enlarged 
prostate  remain  throughout  under  the  care  of  a  surgical  specialist.  It 
is  to  be  remembered  that  the  primary  source  of  discomfort  in  incipient 
cases,  is  irritation  of  the  vesical  neck  incidental  to  the  hypersemia  and 
resulting  hyperplasia  of  the  prostate  and  its  environs.  Hyperacidity 
of  the  urine  and  the  gouty  or  rheumatic  diathesis  are  also  likely  to 
exist.  Proper  measures  of  treatment  to  correct  the  diathetic  condi- 
tion and  remedies  calculated  to  correct  the  irritating  properties  of  the 


424  LYDSTON — DISEASES  OP  THE  PEOSTATE. 

urine  are  always  of  ser-sdce.  Anaphrodisiac  remedies  are  also  fre- 
quently beneficial.  The  remedies  whicli  liave  proven  most  service- 
able in  allaying  vesical  irritability  are,  buchu,  triticum  repens,  san- 
dalwood oil,  copaiva,  ustilago  maidis,  uva  ursi,  ulmus,  and  some 
others  of  a  similar  character.  No  one  of  these  various  remedies  may 
be  said  to  be  equally  satisfactory  in  all  cases.  It  is  very  often  neces- 
sary to  do  some  experimentation  in  order  to  determine  which  remedy 
is  most  eflicacious  in  a  particular  case.  Bromide  of  potassium  and 
ergot  in  full  doses  combined  with  gelsemium  has  seemed  to  be  of 
especial  value  in  the  experience  of  the  author.  This  combination 
not  only  has  a  special  effect  upon  the  involuntary  fibre  and  vascular 
supply  of  the  prostate  but  also  a  special  action  upon  hypersexual 
acti^dty,  which  probably  has  much  to  do  with  the  causation  of  many 
cases.  The  occasional  passage  of  the  sound  and  catheter,  usually 
advised  even  in  incipient  cases  for  the  purpose  of  withdrawing  resi- 
dual urine,  is  beneficial.  In  incipient  cases,  however,  the  benefit  is 
derived,  not  from  the  withdrawal  of  residual  urine,  which,  if  it  be  not 
infected,  has  little  or  no  influence  upon  the  irritation  present,  but  by 
allaying  hyperesthesia  of  the  prostatic  urethra. 

The  general  treatment  is  of  great  importance  in  all  cases  of  pros- 
tatic hypertrophy.  Temperate  habits  and  dietetic  abstemiousness 
are  essential.  If  the  gouty  or  rheumatic  diathesis  exists  the  usual 
preparations  of  colchicum,  lithia,  and  the  salicylates  are  indicated. 
Alkaline  diluents,  mineral  waters,  or  pure  distilled  water  in  large 
quantities  are  of  ser\dce  in  rendering  the  urine  bland  and  unirritating. 
Certain  remedies  have  an  excellent  effect  in  preventing  or  correcting 
decomposition  of  the  urine,  by  their  inhibiting  or  destructive  eft'ect 
upon  the  bacteria  which  bear  so  important  a  relation  to  the  chronic 
cj'stitis  present  in  advanced  cases  of  prostatic  hypertrophy.  The  best 
remedy  which  the  author  has  tried  is  the  oil  of  eucalyptus  in  doses  of 
ten  minims,  four  times  daily,  preferably  after  meals  and  at  bed-time. 
Salol  and  boric  acid  have  been  disappointing.  Benzoate  of  soda, 
naphthol,  guaiacol,  and  small  doses  of  carbolic  acid  are  sometimes 
beneficial.  The  remedies  previously  mentioned  as  having  a  special 
effect  upon  the  vesical  mucous  membrane  are  especially  indicated 
where  cystitis  exists. 

Exercise  in  moderation  is  to  be  recommended.  Horseback  rid- 
ing, bicycling,  and  all  exercises  involving  jolting  movements  of  the 
body  or  pressure  on  the  perineum  should  be  avoided,  especially  if  a 
complicating  calculus  exists.  Exposure,  particularly  such  as  in- 
volves chilling  or  wetting  of  the  feet  and  legs,  is  apt  to  bring  on  acute 
retention  of  urine.  Warm  underclothing  and  protection  from  expo- 
sure to  the  weather  should  therefore  be  insisted  upon. 


HYPERTROPHY  OF  THE  PROSTATE.  425 

In  advanced  cases  it  is  to  be  remembered  tliat  the  principal  source 
of  discomfort  consists  in  the  presence  of  decomposing  residual  urine 
in  the  has  fond.  The  resulting  frequency  of  urination  necessarily 
enhances  the  irritation  and  inflammation  of  the  parts  about  the  neck 
of  the  bladder.  The  first  indication,  therefore,  is  to  prevent  the  re- 
tention and  decomposition  of  residual  urine.  Inasmuch  as  the 
patient  finds  it  impossible  to  empty  his  bladder,  it  is  necessary  to 
supplement  the  normal  function  of  micturition  by  complete  evacua- 
tion of  the  viscus  by  means  of  the  catheter.  In  the  incipiency  of  the 
disease  a  single  complete  evacuation  of  the  bladder  daily  is  often 
sufficient  to  prevent  serious  discomfort  from  the  hypertrophy  for  an 
indefinite  time.  When  the  patient  can  afford  the  necessary  time  and 
expense  it  is  best  that  this  be  done  by  the  physician. 

When  it  is  practicable  for  the  patient  to  evacuate  his  own  bladder 
with  the  catheter,  a  suitable  instrument  should  be  selected  for  him. 
The  only  instrument  with  which  the  average  patient  should  be  en- 
trusted is  some  one  of  the  many  forms  of  soft  catheters.  The  best 
of  these  is  the  Jacques  catheter,  a  soft  and  perfectly  flexible  rubber 
affair,  with  which  the  patient  cannot  possibly  do  himself  injury. 

In  some  instances  this  catheter  is  rather  too  flexible  and  it  is  nec- 
essary to  substitute  some  other  variety.  There  is  a  form  which  is 
of  a  rather  more  substantial  consistency  known  as  the  silk  catheter, 
and  another  equally  serviceable,  the  foundation  of  which  is  Belfast 
linen.  The  writer  much  prefers  these  to  any  other,  and  they  are 
usually  perfectly  safe  to  entrust  to  the  patient.  When  there  is  pro- 
nounced obstruction  at  the  neck  of  the  bladder,  such  as  would  arise 
from  the  existence  of  marked  median  hypertrophy  or  a  bar,  Mer- 
cier's  catheter  coude,  which  is  also  a  soft  instrument,  but  which  has  its 
end  permanently  bent  at  a  slight  angle  or  elbow,  will  be  found  more 
serviceable  than  the  ordinary  flexible  varieties.  The  elbow  at  the 
end  of  the  instrument  serves  to  direct  the  point  up  over  any  barrier 
which  may  obstruct  its  passage  into  the  bladder.  In  some  instances 
the  ordinary  old  style  English  catheter  with  the  stylet  will  be  found 
most  useful  to  the  surgeon,  if  certain  little  details  in  its  manipulations 
are  observed.  Care  should  be  taken  to  keep  the  catheters  scrupu- 
lously clean ;  they  should  be  washed  out  with  a  five-per-cent  solution 
of  carbolic  acid  each  time  they  are  used,  and  when  introduced  should 
be  smeared  with  bichloride  of  mercury  and  vaseline,  1  in  2,000,  a 
little  cocaine  being  added  to  the  ointment  if  the  urethra  and  neck  of 
the  bladder  be  intolerant  of  instruments.  In  advanced  cases  it  is 
desirable  that  the  bladder  be  evacuated  three  or  four  times  in  the 
course  of  the  twenty-four  hours.  In  some  instances  it  is  best  for  the 
patient  to  depend  entirely  ui)on  the  catheter  for  the  evacuation  of  the 


426  LTDSTON — ^DISEASES  OF  THE  PEOSTATE. 

urine.     The  bladder  should  be  washed  out  daily,  and  in  severe  cases 
several  times  daily,  with  a  warm  antiseptic  solution;  bichloride  of 
mercury,  1  in  20,000,  carbolic  acid  in  half-per-cent  solution,  and  a 
saturated  solution  of  boracic  acid  are  all  useful  for  this  purpose. 
The  following  combination  is  of  service : 

i^     Sodii  biboratis §  ij. 

Acidi  carbolic! §  i  j . 

Glycerini q.  s.  ad    3  vii j . 

M.    Sig.    §  ss.  in  a  quart  of  warm  water  as  an  irrigating  fluid. 

The  irrigating  lotion  should  be  moderately  warm,  or,  if  it  seems 
desirable,  as  hot  as  can  be  borne.  There  is  no  better  apparatus  for 
irrigation  than  an  ordinarj^  fountain  syringe  with  or  without  a  soft 
catheter.  The  fluid  should  be  allowed  to  enter  the  bladder  in  a  small 
quantity  at  a  time,  for  if  the  inflamed  bladder  be  distended  greatly 
an  increase  of  irritation  will  result,  and  perhaps  pain  will  be  pro- 
duced by  the  operation.  After  each  irrigation  it  is  advisable  to  leave 
about  two  ounces  of  fluid  in  the  bladder.  Wlien  cystitis  is  severe 
the  daily  prolonged  use  of  the  hot  sitz-bath,  preferably  on  retiring 
for  the  night,  is  of  service.  Further  expatiation  upon  the  treatment 
of  complicating  cystitis  is  hardly  necessary,  as  it  has  received  full 
consideration  in  the  chapter  on  diseases  of  the  bladder. 

Should  retention  of  urine  come  on  in  the  course  of  the  case,  it 
should  be  relieved  as  quickly  as  possible,  as  typhoid  symptoms  are 
apt  to  supervene  rapidly  in  these  elderly  and  debilitated  patients. 
Morphine  in  small  doses  and  the  general  hot  bath  will  facilitate  sur- 
gical measures  for  the  relief  of  the  retention.  A  soft  catheter  should 
be  passed  if  possible,  and  failing  in  this,  the  ordinary  gum  catheter 
with  a  stylet  may  be  used.  The  stylet  should  be  curved  to  conform 
with  the  prostatic  urethra,  and  care  should  be  taken  not  to  exert 
much  force  upon  the  catheter  in  its  introduction,  as  the  point  will 
very  often  catch  at  the  point  of  obstruction.  Under  such  circum- 
stances the  instrument  may  often  be  successfully  passed  by  pressing 
against  it  just  below  its  point,  with  the  index  finger  introduced  into 
the  rectum.  The  finger  in  this  instance  acts  as  a  fulcrum,  and  the 
force  employed  in  passing  the  catheter  is  expended  against  it  instead 
of  the  prostatic  obstruction  or  bar.  This  little  manoeuvre  will  often 
succeed  where  the  introduction  of  an  instrument  would  be  otherwise 
impossible.  It  will  be  found  that  with  this  semi-flexible  instrument 
the  pressure  of  the  finger  just  in  front  of  the  anus  will  often  answer 
the  same  purpose,  the  handle  of  the  catheter  being  depressed,  simul- 
taneously with  the  application  of  pressure  to  the  portion  occupying 
the  deep  urethra.     It  will  be  seen  that  in  manoeuvres  of  this  kind  an 


HYPERTROPHY  OF  THE  PROSTATE.  427 

accurate  knowledge  of  tlie  conformation  of  the  distorted  uretlira  is 
necessary.  There  is  no  danger  in  employing  tolerably  firm  pressure 
after  the  surgeon  becomes  moderately  expert  in  this  method  of  jjro- 
cedure,  providing  such  pressure  be  received  upon  the  finger  applied 
to  the  bend  of  the  catheter  in  the  perineum. 

Another  little  manoeuvre  which  will  be  found  to  be  very  efficacious 
is  the  following :  The  stylet  having  been  given  an  exaggerated  curve 
is  passed  into  the  catheter  and  the  latter  introduced  into  the  urethra 
until  it  comes  in  contact  with  the  obstruction;  the  point  is  now 
pressed  with  moderate  firmness  against  the  obstruction  with  the  fin- 
gers of  the  left  hand  upon  the  handle,  and  the  stylet  is  withdrawn, 
while  the  catheter  is  pushed  steadily  forward,  It  will  be  found  that, 
as  a  rule,  the  withdrawal  of  the  stylet  will  curl  the  point  of  the  cathe- 
ter upward  and  forward,  in  such  a  manner  that  the  point  of  the  in- 
strument readily  glides  snakewise  up  over  the  obstruction  and  into 
the  bladder. 

When  it  is  found  to  be  impossible  to  introduce  a  flexible  or  semi- 
flexible  instrument  Thompson's  silver  or  Gross'  jointed  metallic 
catheter  may  be  used.  In  extreme  cases  it  may  be  found  necessary 
to  aspirate,  or  in  lieu  of  an  aspirator  to  use  a  small  trocar.  Dieula- 
foy's  aspirator  is  the  best  for  the  purpose.  The  operation  of  tap- 
ping may  be  repeated  a  number  of  times  if  necessary  while  waiting 
for  the  acute  congestion  of  the  parts  about  the  neck  of  the  bladder  to 
subside,  after  which  the  urine  either  flows  readily  or  may  be  evacu- 
ated by  the  catheter.  Should  a  trocar  be  used  in  lieu  of  the  aspira- 
tor, it  may  be  passed  into  the  bladder  above  the  pubes,  or  through 
the  rectum.  In  the  latter  event  a  very  small  curved  instrument 
should  be  used,  the  bladder  being  punctured  in  the  trigonum  vesicae 
just  above  the  border  of  the  prostate.  Should  median  hypertrophy 
exist  and  fluctuation  at  this  point  be  absent,  rectal  puncture  will  be 
impracticable.  When  the  trocar  is  used,  it  is  well  to  leave  the  can- 
nula in  situ  until  it  becomes  practicable  to  evacuate  the  bladder  by 
means  of  the  catheter. 

If  retention  has  existed  for  some  little  time,  care  should  be  taken 
not  to  evacuate  the  bladder  completely,  lest  there  be  set  up,  as  a  con- 
sequence of  removal  of  pressure  from  the  already  weakened  vesical 
walls,  acute  inflammation  and  sloughing  with  an  inevitably  fatal  re- 
sult. It  has  been  shown  experimentally  that  this  is  due  to  acute 
bacterial  infection,  the  resistance  of  the  tissues  having  been  lessened 
by  the  circulatory  disturbance.  Such  accidents  are  not  so  rare  as 
might  be  supj)osed. 

In  a  day  or  two,  after  the  bladder  has  contracted  down  somewhat, 
it  is  advisable  to  evacuate  it  comi)letely  at  each  seance.     The  writer 


428  LYDSTON — DISEASES  OF  THE  PROSTATE. 

has  in  some  instances  emptied  tlie  bladder  completely  at  once,  but  bas 
followed  its  evacuation  by  irrigation  with  a  warm,  mild  antiseptic 
solution,  a  sufficient  quantity  of  the  irrigating  fluid  being  left  in  the 
bladder  to  moderately  distend  its  walls. 

It  will  be  found  that  very  few  cases  will  require  the  aspirator  if 
the  catheter  be  intelligently  used. 

It  should  be  remembered,  in  connection  with  the  subject  of  reten- 
tion, that  after  a  time  the  urine  is  likely  to  dribble  away  as  a  conse- 
quence of  overflow.  This  may  mislead  the  practitioner  into  the  belief 
that  there  is  no  longer  amy  necessity  for  the  evacuation  of  the  blad- 
der. Many  an  old  man  has  been  allowed  to  die  unrelieved  because  of 
the  ignorance  of  the  physician  on  this  point. 

Bibliography. 

Home,  E.  :  Practical  Observation  on  the  Treatment  of  Diseases  of  the  Prostate 
Gland.      London,  1811-18. 

Thompson,  Sir  H.  :  The  Diseases  of  the  Prostate  :  their  Pathology  and  Treat 
ment.     London,  1886. 

Segond,  P.  :  Des  Absces  Chauds  de  la  Prostate  et  du  Phlegmon  Periprostatique. 
Paris,  1880. 

Coulson,  W.  :  On  Diseases  of  the  Bladder  and  Prostate  Gland.  New  York, 
1881. 

Guyon,  J.  C.  F.  :  Lecous  Cliniqaes  sur  les  Affections  Chirurgicales  de  la  Vessie 
et  de  la  Prostate.     Paris,  1888. 

Belfield,  W.  :  Art.  Prostate,  in  Morrow's  System  of  Gen ito- urinary  Diseases, 
Syphilology,  and  Dermatology.     Vol.  i.     New  York,  1893. 

Gross,  S.  D.  :  A  Practical  Treatise  on  the  Diseases,  Injuries,  and  Malformations 
of  the  Urinary  Bladder,  the  Prostate  Gland,  and  the  Urethra.     Philadelphia,  1876. 

On    Prostatorrha3a.     North   American   Medico-Chirurgical   Eeview. 

Philadelphia,  1860. 

Petit,  Jean  Louis :  Traite  des  Maladies  Chirurgicales.  Ouvrage  posthume. 
Edited  by  M.  Lesne.     Paris,  1774. 

Lallemand,  Claude  Franyois  :  Observations  sur  les  Maladies  des  Organes  Genito- 
urinaires.     Paris,  1827. 

Lagneau,  Louis  Vivant :  Sur  le  Traitement  de  la  Maladie  Venerienne,  et  ses 
differeutes  modifications  selon  I'Sge,  les  maladies,  etc.     Paris,  1815. 

Moullin,  C.  W.  Mansell :  The  Operative  Treatment  of  Enlarged  Prostate. 
London,  1892. 

Flirbringer,  P.  :  Traite  des  Maladies  Genito-urinaires.  Version  frangaise,  par 
G.  Caussade.     Paris,  1892. 

Boyer  :  Traite  des  Maladies  Chirurgicales.     Paris,  1824. 

Lannelongue  :  Bulletin  de  la  Societe  de  Chirurgie,  1878. 

Desault,  P.  J.  :  ffiuvres  Chirurgicales.     Paris,  1813. 

Mercier,  L.  A.  :  Recherches  Anatomiques,  Pathologiques  et  Therapeutiques  sur 
les  Maladies  des  Organes  Urinaires  et  Genitaux.     Paris,  1841. 

Brodie,  Sir  B.  :  Lectures  on  the  Urinary  Organs.     London,  1842. 

LeFort,  J.  :  Calculs  de  la  Prostate.     Bulletin  de  la  Societe  de  Chirurgie,  1874. 

Reclus  :  Calculs  Multiples.     Bulletin  de  la  Societe  de  Chirurgie,  1885. 


BIBLIOGRAPHY.  429 

Verdier  :  Observations  sur  les  Phlegmons  de  la  Prostate.     Paris,  1838. 

Le  Dentu  :  Kyste  de  la  Prostate.     Bulletin  de  la  Societe  de  Chirurgie,  1888. 

Simmonds :  Ueber  Tuberculose  des  mannlichen  Genital-Apparats.  Deutsches 
Archiv  fiir  klinische  Medicin,  Bd.  xxxvii. 

Tapret ;  Tuberculose  des  Voies  Urinaires.    Archives  Generales  de  Medecine,  1878. 

Terrillon  :  Tuberculose  Genitale.      Gazette  des  Hopitaux,  1884. 

Eeliquet,  Emile  ;  Lemons  sur  les  Maladies  des  Voies  Urinaires.     Paris,  1878. 

Hunter,  John  :  A  Treatise  on  the  Venereal  Disease.     London,  1788. 

Amussat,  J.  Z.  :  Leyons  sur  les  Eetentions  d' Urine  et  sur  les  Maladies  de  la 
Prostate.     Paris,  1833. 

Desnos  et  Kirmisson  ••  Transformation  fibrineuse  des  Tissus  periprostatiques. 
Annales  des  Maladies  des  Organes  Genito- urinaires,  1889. 

Finger  :  Prostatitis  und  Spermato-Cystitis.     Wiener  medizinische  Presse,  1885. 

Wilson,  J.  :  Lectures  on  the  Structure  and  Physiology  of  the  Male  Urinary  and 
Genital  Organs,  London,  1821. 

Bell,  Sir  Charles  :     Medico-Chirurgical  Transactions,  1812. 

Belfield,  William :  Diseases  of  the  Urinary  and  Male  Sexual  Organs,  New 
York,  1884. 

White,  J.  Wm.  :  Castration  for  Enlarged  Prostate.     Annals  of  Surgery,  1894. 

Harrison,  Reginald  :  Lectures  on  the  Surgical  Disorders  of  the  Urinary  Organs, 
2d  Ed.,  London,  1880. 

Lydston,  G.  Frank :  Passive  Congestion  of  the  Prostate  in  its  Relations  to 
Haematuria.     Medical  Era,  December,  1887. 

The  Etiology  of  Prostatic  Hypertrophy.  Medical  and  Surgical  Re- 
porter, May  13,  1893. 

Modern  Bacteriological  Research  in  its  Relations  to  Genito -Urinary  Sur- 
gery.    International  Medical  Magazine,  June,  1893. 

The  Present   Status  of   the   Surgery  of  the  Prostate.     International 

Journal  of  Surgery,  September,  1893. 

Remarks  on  the  Relation  of  Residual  Urine- to  Vesical  Irritation,  es- 
pecially In  Prostatiques.     International  Medical  Magazine,  September,  1894. 


DISEASES  OF  THE  MALE  URETHRA. 

BY 

G.  FRANK  LYDSTON, 

CHICAGO. 


DISEASES  OF  THE  MALE  URETHRA. 


It  is  hardly  necessary  in  a  work  of  this  kind  to  enter  into  an 
elaborate  description  of  the  anatomy  and  physiology  of  the  male 
urethra.  There  are  a  few  points,  however,  which  are  of  practical 
interest  in  the  clinical  and  pathological  study  of  its  diseases.  The 
urethra  may  be  described  as  a  musculo-membranous  tube  extending 
from  the  meatus  uriuarius  to  the  bladder.  It  is  divided  into  three 
portions,  the  penile,  spongy,  or  pendulous  urethra,  the  membranous, 
and  the  prostatic.  The  two  latter  comprise  the  fixed  or  deep  urethra. 
The  spongy  or  penile  urethra  is  about  six  inches  in  length  and  extends 
from  the  meatus  urinarius  to  the  opening  in  the  triangular  ligament, 
at  which  point  it  joins  the  pars  membranosa.  The  latter  is  about 
three-fourths  of  an  inch  in  length  and  extends  from  the  anterior  to 
the  posterior  layer  of  the  triangular  ligament;  the  balance  of  the 
canal  is  comprised  in  the  prostatic  portion,  which  is  about  one 
and  one-fourth  inches  long.  The  meatus  urinarius  is  the  nar- 
rowest portion  of  the  canal  for  the  obvious  purpose  of  better 
directing  the  outflowing  semen  and  urine.  The  meatus  varies  con- 
siderably in  size.  A  small  meatus  is  not  necessarily  an  indica- 
tion for  a  surgical  operation,  but  when  a  small-calibred  orifice 
is  associated  with  urethral  disease  or  possible  reflex  disturbance  of 
the  genito-urinary  tract,  a  congenital  contraction  of  the  meatus  at 
once  assumes  surgical  importance.  The  meatus  is  sometimes  nar- 
rowed because  of  the  comparatively  great  thickness  of  that  portion  of 
the  glans  forming  the  floor  of  the  fossa  navicularis,  the  latter  being 
the  relatively  dilated  portion  of  the  urethra,  situated  within  the 
boundaries  of  the  glans  penis  and  terminating  at  the  junction  of  the 
latter  with  the  corpora  cavernosa.  In  other  cases  the  relative  narrow- 
ness of  the  meatus  is  due  to  a  thin  membranous  fold  at  the  inferior 
commissure  of  the  orifice.  This  is  dilatable  and  offers  little  or  no  re- 
sistance to  instrumentation,  the  contrary  being  true  of  the  variety  of 
narrowing  previously  mentioned.  Narrowness  of  the  meatus  is  usu- 
ally congenital,  destructive  ulceration  being  the  usual  cause  of  ac- 
quired contraction.  In  some  instances  the  canal  is  relatively  narrow 
because  of  the  j)reHence  of  a  congenital  band  just  within  the  meatus, 
the  orifice  proper  being  fairly  dilatable. 
Vol.  I.— 28 


434  LYDSTON— DISEASES   OF  THE  IMALE  UKETHEA. 

The  spongy  urethra  is  so-called  because  of  its  investment  by  the 
corpus  spongiosum.  The  mucous  membrane  of  this  portion  of  the 
canal  is  abundantly  supplied  with  mucous  glands  and  ducts.  These 
when  infected  are  likely  to  become  dilated  and  their  orifices  more  or 
less  obstructed  with  a  resultant  accumulation  of  infectious  products 
in  the  glandular  tissue  proper.  Latent  infection  and  successive  auto- 
inoculations  with  gonorrhoea  are  often  thereby  explained.  As  is 
well  known,  these  ducts  and  follicles  may  be  so  dilated  that  they  catch 
the  points  of  instruments  emploj^ed  in  exploration  of  the  urethra. 
They  may  also  be  the  starting-point  of  urinary  abscess  and  fistula. 
Their  abundance  and  the  difficulty  of  rendering  them  aseptic  is  a 
logical  explanation  of  the  obstinacy  of  some  cases  of  urethritis. 

The  membranous  portion  of  the  canal  is  invested  by  relatively 
powerful  layers  of  longitudinal  and  circular  muscular  fibres,  the  com- 
pressor urethrse  and  accelerator  urinse  muscles.  On  this  account  it 
has  been  sometimes  termed  the  muscular  portion.  The  function  of 
the  muscular  structures  of  the  urethra  is  very  important.  That  of  the 
membranous  urethra  constitutes  the  true  sphincter  of  the  bladder. 
This  muscular  tissue  is  under  the  volitional  control  of  the  patient,  but 
in  rather  a  peculiar  fashion.  It  would  seem  that  the  sympathetic  nerve 
fibres  supplied  to  the  muscle  are  responsible  for  its  normal  tonicity. 
Voluntary  nerve  fibres  supplied  to  the  part  enable  the  patient  to  in- 
hibit the  normal  contraction  at  will,  as  a  consequence  of  which  the 
steady  pressure  or  normal  tonus  of  the  detrusor  urinae  muscle  is  en- 
abled to  overcome  the  slight  remaining  resistance  of  the  true  vesical 
sphincter,  with  resulting  voluntary  micturition.  Direct  or  reflex  ex- 
citation of  this  portion  of  the  canal  is  likely  to  result  in  retention  of 
urine.  Conversely,  paralysis  of  the  pars  membranosa  produces 
urinary  incontinence. 

The  prostatic  portion  of  the  urethra  has  received  attention  in  con- 
nection with  the  anatomy  of  the  prostate.  The  principal  diseases  of 
this  part  of  the  canal  have  also  received  consideration  as  prostatic 
rather  than  urethral  affections.  While  the  urethra  is  under  normal 
circumstances  a  urinary  organ,  it  is  by  no  means  necessary  to  the 
function  of  micturition.  It  is,  however,  quite  necessary  to  the  pro- 
creative  act.  The  urethra  is,  therefore,  a  sexual  rather  than  a  uri- 
nary organ. 

The  length  of  the  urethra  as  given  by  most  anatomists  is  from 
eight  to  nine  inches,  but  the  greatest  discrepancy  exists  upon  this 
particular  point.  A  table  showing  the  estimates  of  various  clinical 
observers  would  show  a  marked  variance  of  opinion.  A  difference  of 
from  twenty  to  thirty  per  cent,  in  the  estimated  measurements  of 
equally  competent  observers  is  not  unusual,  and  is  hardly  to  be  won- 


INJUEIES   OF   THE   URETHEA.  435 

dered  at.  It  is  probable  that  no  two  observers  can  possibly  obtain 
precisely  similar  conditions  for  measurement.  The  penis  varies 
in  size  not  only  intrinsically  in  different  subjects,  but  there  is  the 
greatest  imaginable  variation  in  the  same  subject  under  different 
psychological  conditions.  The  same  conditions  affect  the  calibre  of 
the  canal. 

The  individual  urethra  is  a  law  unto  itself  as  far  as  its  length  is 
concerned.  The  length  of  a  particular  urethra  may  be  said  to  be  the 
distance  from  the  meatus  traversed  by  the  catheter  before  the  urine 
begins  to  flow,  the  penis  being  flaccid  and  placed  upon  a  degree  of 
tension  merely  sufficient  to  afford  adequate  support  during  instru- 
mentation. Due  allowance  should  be  made  for  sexual  excitation  or 
emotional  inhibition. 

The  anterior  curve  of  the  urethra  is  not  of  great  imjDortance  with 
relation  to  instrumentation,  as  it  can  be  adapted  to  almost  any  form 
of  instrument.  It  is  different,  however,  with  the  posterior  or  deep 
curve,  which  is  relatively  fixed;  it  cannot  be  said  to  be  constantly 
fixed,  for,  as  is  well  known,  straight  instruments  can  be  intro- 
duced into  the  bladder.  The  fixed  urethral  curve  is  not  uniform,  but 
varies  widely  with  the  period  of  life  and  the  condition  of  the  prostate 
body.  It  is  comparatively  short  and  sharp  in  the  child,  much 
longer  and  less  abrupt  in  the  adult,  these  characteristics  greatly  in- 
creasing in  prominence  as  the  subject  grows  older.  In  prostatic  en- 
largements the  curve  becomes  so  greatly  elongated  as  to  necessitate 
considerable  modification  of  instruments  and  in  manipulations  for  en- 
tering the  bladder.  This  point  is  of  the  greatest  practical  impor- 
tance to  the  genito-urinary  surgeon.  The  direction  and  conforma- 
tion of  the  pendulous  urethra  may  be  modified  by  changes  in  the 
position  of  the  penis.  It  may  also  be  adapted  to  any  form  of  instru- 
ment necessary  for  urethral  or  bladder  manipulation. 

The  average  normal  curve  as  established  by  Bell,  and  verified  by 
Thompson,  Van  Buren,  and  others,  corresponds  to  a  circle  three  and 
one-fourth  inches  in  diameter,  the  proper  length  of  curve  for  adapta- 
tion to  the  deep  urethra  being  an  arc  of  such  a  circle  subtended  by  a 
chord  two  and  three-fourths  inches  in  length.  The  length  of  curve, 
as  outlined  by  Thompson,  is  generally  too  long  for  instruments.  The 
shorter  the  beak  of  the  sound — providing  it  be  adapted  to  the  normal 
cuiwe — the  more  thoroughly  under  control  will  the  instrument  be 
during  instrumentation. 

INJURIES   OF  THE  URETHRA. 

The  subject  of  urethral  traumatisms  is  strictly  surgical,  yet  the 
general  practitioner  is  quite  often  called  upon  to  treat  this  class  of 


Possible  results  of 
urethral  traumatism. 


436  LYDSTON — DISEASES   OF  THE  MAI^E  UEETHRA. 

injuries.  A  knowledge  of  the  proper  method  of  management  of  trau- 
matisms of  the  urinary  canal  is  of  the  greatest  importance,  not  only 
because  of  the  immediate  gravity  of  many  cases,  but  because  of  the 
more  remote  yet  serious  results  which  may  follow  apparently  trivial 
injuries. 

The  urethra  may  be  contused,  lacerated,  or  cut  either  from  inter- 
nal or  external  violence.  Internal  injuries  are  generally  the  result  of 
surgical  interference  with  the  canal ;  occasionally,  however,  the  pa- 
tient wounds  his  urethra  by  the  introduction  of  foreign  bodies  of  vari- 
ous kinds.  The  penile  urethra  is  only  exceptionally  injured  by  exter- 
nal violence  on  account  of  its  extreme  mobility.  The  deep  urethra  is 
frequently  injured  by  falls  or  blows  upon  the  perineum,  the  bulbo- 
membranous  region  being  caught  between  the  impinging  body  and  the 
sharp  lower  border  of  the  subpubic  ligament.  A  slight  blow  in  this 
region  may  produce  serious  injury. 

The  urethra  is  occasionally  cut  or  lacerated  from  external  blows 

with  sharp  instruments. 

'  Hemorrhage. 
Retention  of  urine. 
Extravasation  of  urine. 
False  passages. 
-^  Urethritis. 
Pus  infection  and  abscess. 
Urinary  fistula. 

Permanent  curvature  of  the  penis. 
Stricture  of  the  most  intractable  form. 

Treatment. 

In  slight  injuries  of  the  urethra,  the  practitioner  must  have  in 
view  the  danger  of  subsequent  stricture.  This  may  bfe  averted  by 
systematic  sounding  during  the  healing  of  the  wound.  Hemorrhage 
may  be  controlled  by  pressure,  the  ice-bag,  or  the  retained  catheter. 
If  the  injury  be  at  aU  extensive  and  a  catheter  can  be  readily  passed, 
it  should  be  retained  in  the  bladder  for  a  few  days,  after  which  the 
danger  of  extravasation  will  have  subsided.  Systematic  dilatation 
should  now  be  substituted  for  the  retained  catheter.  If  the  penile 
urethra  be  extensively  lacerated,  a  perineal  pimcture  should  be 
made  for  vesical  drainage  and  the  lacerated  tissues  should  be  stitched 
in  layers  over  a  soft  catheter  or  a  piece  of  rubber  tubing.  The  peri- 
neal tube  may  be  removed  at  the  end  of  a  week.  Primary  union  may 
be  expected  from  this  procedure. 

In  all  urethral  injuries  great  care  should  be  taken  in  passing 
instruments  lest  the  lacerated  tissues  be  torn  up  and  a  false  passage 
thereby  made. 

In  deep  urethral  injuries  a  catheter  should  be  carefully  passed 


FOEEIGN  BODIES   IN  THE  URETHRA — URETHRITIS.  437 

and  retained  for  a  week  or  more,  after  wliicli  dilatation  should  be  be- 
gun. If  great  difficulty  be  experienced  in  passing  the  catheter,  or  if 
the  injury  be  severe,  perineal  section  is  indicated.  If  it  be  possible 
to  suture  any  portion  of  the  divided  urethra,  this  procedure  is  ad- 
visable. The  author  is  of  the  opinion  that  perineal  section  is  by  far 
the  safest  method  of  treatment  for  the  majority  of  cases  of  injury  to 
the  perineal  portion  of  the  urethra.  Should  extravasation  of  urine 
be  suspected  perineal  section  is  imperatively  necessary. 

In  the  management  of  all  cases  of  urethral  injury,  the  strictest 
attention  should  be  paid  to  asepsis  and  antisepsis.  The  most  im- 
portant practical  point  in  connection  with  urethral  traumatism  is  the 
fact  that  stricture  of  the  canal  often  follows  injuries  which  are  so 
trivial  as  to  attract  little  or  no  attention  at  the  time  of  their  inflic- 
tion.    Careful  attention  may  obviate  this  untoward  result. 

FOREIGN   BODIES  IN   THE  URETHRA. 

Numerous  substances  have  been  introduced  into  the  urethra  by 
masturbators  and  by  individuals  who  are  possessed  of  more  curiosity 
than  good  sense.  Fragments  of  catheters  and  other  surgical  instru- 
ments are  occasionallv  broken  off  in  the  urethra. 


Possible 
results. 


r  Retention  of  urine. 
Urethritis. 
Ulceration. 
Abscess  and  fistula. 
Deposition  of  urinary  salts  and  resulting  calculous  formation. 

Treatment. 

Simple  manipulation  perhaps  combined  with  meatotomy  is  often 
successful  in  removing  foreign  bodies  from  the  urethra.  Specially 
constructed  urethral  forceps  are  sometimes  necessary.  When  these 
means  fail,  the  foreign  body  should  be  pushed  on  into  the  perineal 
urethra,  a  perineal  section  being  first  made.  It  is  well  to  make  the 
perineal  section  before  the  foreign  body  is  pushed  down,  unless  it  be 
of  good  size,  for  small  bodies  may  otherwise  be  forced  into  the  bladder. 

URETHRITIS. 

Urethritis  is  the  most  frequent  disease  affecting  the  male  genito- 
urinary tract.  It  is  usually  contracted  during  sexual  iutercourse  and 
is  so  exceptionally  acquired  in  any  other  way  that  it  has  been 
termed  the  most  venereal  of  the  class  of  diseases  to  which  it  belongs. 
The  most  common  term  for  urethritis  is  gonorrhoea.     This  is  a  mis- 


438  LYDSTON — DISEASES   OE  THE  MALE  URETHRA. 

nomer  for  several  reasons :  First,  becaiise  it  implies  a  discliarge  or 
morbid  flow  of  semen;  second,  because  it  implies  a  disease  of  an 
unvarying  type  of  specificit3\  Tlie  generic  term  urethritis  is  accu- 
rate as  applied  to  tlie  affection  in  the  male,  inasmuch  as  it  not  only 
implies  an  inflammation  of  the  urethral  mucous  membrane,  but  is 
sufficiently  comprehensive  to  embrace  all  the  varying  forms  of  the 
disease  whatever  their  origin.  Neisser's  discovery  of  the  gonococcus 
has,  however,  in  all  probability  permanently  fixed  the  generic  term 
gonorrhoea  in  its  application  to  a  specific  type  of  inflammation  afi^ect- 
ing  the  mucous  membranes  in  both  the  male  and  female.  If  we 
accept  the  specific  character  of  the  gonococcus,  a  broad  line  of  clini- 
cal differentiation  is  at  once  established  in  urethritis.  We  are  still 
compelled  to  recognize,  however,  certain  cases  in  which  the  presence 
or  absence  of  the  gonococcus  cannot  be  accepted  as  proving  or  dis- 
proving the  origin  of  the  disease  in  any  particular  venereal  act.  This 
is  especially  true  in  cases  in  which  the  affected  individual  has  in- 
dulged at  more  or  less  frequent  intervals  with  different  females,  and 
has  suffered  from  pre\dous  urethral  infection.  Under  such  circum- 
stances the  recent  attack  may  have  been  due  to  the  development  of 
gonococcal  auto-infection  from  a  focus  originating  in  some  prior 
attack  of  inflammation.  In  other  instances  the  jjatient  presents 
himself  with  a  non-gonococcal  discharge,  and  we  are  called  upon  to 
decide  as  to  its  specificity.  Here  we  are  compelled  to  acknowledge 
that  the  gonococci  may  have  been  present,  but  have  disappeared. 
Practically,  therefore,  we  are  often  essentially  in  the  same  position 
as  before  the  discovery  of  the  gonococcus.  Especially  is  this  true 
from  a  medico-legal  standpoint.  The  sources  of  error  in  the  diag- 
nosis of  the  origin  of  urethritis  are  so  numerous  that  it  is  never  safe 
to  pronounce  a  case  of  urethritis  to  be  of  specific  origin,  whether  the 
gonococcus  be  present  or  not,  unless  the  affected  individual  can  be 
shown  to  have  been  perfectly  healthy  before  the  development  of 
urethritis,  or  to  have  had  intercourse  with,  a  woman  suffering  from 
virulent  vaginitis,  or  to  have  a  history  of  a  more  or  less  recent  attack 
of  gonorrhoea.  This  caution  is  particular^'-  necessary  in  passing  an 
opinion  in  the  case  of  a  married  person. 

The  discovery  of  the  gonococcus  has  not  changed  the  views  of  the 
author  regarding  the  origin  of  gonorrhoea  and  its  congeners.  This 
class  of  affections,  in  common  with  chancroid,  may  still  be  classed 
as  filth  diseases  which  originate  de  novo  in  the  female.  The  author 
believes  that  germ  infection  of  one  kind  or  another  is  the /ons  et  origo 
of  the  majority  of  cases  of  urethritis.  It  is  not  probable,  however, 
that  the  germs  producing  such  infection  are  always  and  invariably 
the  same.     Gonorrhoea  is  as  old  as  the  human  race,  but  that  the 


UEETHRITIS.  439 

gonoccoccus  was  originally  the  result  of  a  special  act  of  creation 
seems  incomprehensible.  The  development  of  the  gonococcus,  and 
indeed  of  all  germs  capable  of  producing  urethral  inflammation,  has 
been  along  evolutionary  lines.  We  cannot  accept  the  spontaneous 
generation  of  germs  of  a  specific  type.  We  may,  however,  believe  in 
the  transformation  of  innocuous  germs  by  virtue  of  their  adaptation 
to  environment,  into  germs  of  a  specifically  pathogenic  character. 
The  female  generative  apparatus  constitutes  the  most  favorable  en- 
vironment for  the  development  of,  and  acquirement  of  pathogenic 
properties  by,  germs  that  could  be  imagined.  Protection  from  air  and 
light,  and  the  presence  of  heat,  moisture,  and  decomposable  secretions 
of  various  kinds  constitute  an  excellent  field  for  bacterial  evolution. 
Pathological  discharges  and  exposure  of  the  parts  to  sources  of  local 
irritation  constitute  an  additional  and  important  factor.  In  un- 
cleanly women,  both  pathological  and  physiological  discharges  of  the 
male  are  allowed  to  accumulate  and  undergo  decomposition.  The 
semen  is  a  highly  complex  organic  substance,  the  decomposition  of 
which  in  all  probability  results  in  the  development  of  toxines  of  a 
highly  irritating  character. 

Whether  or  not  the  gonococcus  be  accepted  as  the  cause  of  a  certain 
specific  type  of  urethritis,  the  fact  remains  that  the  environmental 
conditions  which  have  been  mentioned  constitute  the  point  of  departure 
of  germ  evolution,  the  products  of  which  are  capable  of  producing 
mucous  inflammation  of  varying  grades  of  severity,  ranging  from  a 
simple  form  of  urethritis  to  the  gonococcal  variety  of  virulent  inflam- 
mation. Precisely  what  germ  is  the  progenitor  of  the  gonococcus  in 
the  process  of  evolution  would  be  difiicult  to  determine,  but  the  differ- 
ence between  the  specific  microbe  and  certain  germs  which  are  nor- 
mally present  in  the  urethra  of  the  male  and  vagina  of  the  female 
is  not  very  great.  The  dissimilarity  between  the  gonococcus  and 
the  pus  microbe  is  not  so  marked  as  to  exclude  the  possibility  of  the 
transformation  of  the  one  into  the  other  under  favorable  circum- 
stances of  environment.  That  we  are  unable  to  imitate  this  process 
of  evolution  is  not  a  valid  argument  against  the  theory. 

Varieties. 

Urethritis  may  be  divided  into : 

r  Bacterial. 

f       a-      ^  Toxic. 

,      ,         ,    ,        .  «•   Simple j  Chemical. 

Acute  and  chronic.  . . .  j  [ Tra.imatic. 

\_b.   Specific Gonococcal. 


440  lydston — diseases  of  the  male  ueethea. 

Simple  Urethkitis. 

Predisposing  Causes. — 1,  Diathetic  conditions ;  2,  chronic  urethral 
disease ;  3,  morbid  states  of  the  urine ;  4,  sexual  abuses ;  5,  dietetic 
excesses  and  irregularities;  6,  alcoholism.  It  is  obvious  that  any 
condition  of  the  sj^stem  which  gives  rise  to  irritability  of  the  mucous 
membranes  predisposes  to  inflammation  of  these  structures.  It  is 
possible  that  this  argument  cannot  be  applied  with  equal  pertinency 
to  all  mucous  membranes,  but  it  certainly  applies  quite  forcibly  to 
the  urethra.  Especially  is  this  true  of  such  diathetic  conditions  as 
rheumatism  and  gout,  in  which  the  urine  is  likely  to  be  loaded  with 
the  products  of  retrograde  tissue  metamorphosis,  which  products 
may  be  both  mechanically  and  chemically  irritating.  Lithsemia  and 
oxalsemia  are  especially  potent  factors  in  this  respect,  producing  as 
they  do  their  corresponding  conditions  of  perturbation  of  the  composi- 
tion of  the  urine,  ^dz. ,  lithuria  and  oxaluria.  The  urine  in  lithsemia  is 
not  only  likely  to  be  heavy  and  concentrated  by  virtue  of  its  dispropor- 
tionate amount  of  solids,  but  the  uric-acid  crystals  present  are  exceed- 
ingly irritating  to  the  mucous  membranes  of  the  genito-urinary  tract. 
There  is  no  question  but  that  lithuria  is  responsible  for  certain 
catarrhal  conditions  of  the  superior  portion  of  the  genito-urinary 
apparatus.  This  catarrhal  condition  is  possibly  not  so  manifest  in 
the  urethra,  yet  the  mucous  membrane,  by  virtue  of  the  irritating 
properties  of  the  urine,  is  in  an  extremely  vulnerable  condition. 
This  constitutes  a  standing  in^dtation  to  infection  and  sources  of  irri- 
tation of  all  kinds.  Irritability  of  the  nervous  supply  of  various  tis- 
sues, which  means  essentially  irritability  of  the  tissues  themselves, 
is  another  important  factor  incidental  to  the  gouty  or  rheumatic  dia- 
thesis. Closely  associated  with  the  gouty  diathesis  are  the  effects 
of  dietetic  indiscretions  and  excesses,  and  indulgence  in  alcoholic 
beverages. 

As  is  true  of  aU  organs  of  the  body,  excessive  action  is  a  pre- 
disposing cause  of  inflammation.  In  the  case  of  the  urethra  sexual 
excesses  and  masturbation  are  the  source  of  much  mechanical  dis- 
turbance, glandular  hyjjeractivity  with  excessive  secretion  of  mucus, 
and  possibly  slight  traumatisms,  these  various  factors  causing  a  catar- 
rhal state  of  the  mucous  membrane  which  affords  excellent  soil  for 
microbial  action,  and  exaggerates  the  results  of  irritation  of  all  kinds. 

By  far  the  most  important  factor  in  the  predisposing  causes  of 
simple  urethritis  is  chronic  disease  of  the  genito-urinary  tract,  what- 
ever its  origin  may  have  been.  Most  of  the  so-called  cases  of  bas- 
tard clap  or  simple  urethritis  are  due  to  the  effects  of  sexual,  alco- 
holic, or  dietetic  excesses  upon  a  urethra  already  damaged,  and  in 


SnvtPLE  "DEETHEITIS.  441 

wliicli  the  products  of  microbial  action,  particularly  the  products  of 
simple  decomposition,  are  present.  This  must  be  remembered  as 
bearing  very  pertinently  upon  cases  of  suspected  gonorrhoea  in  whi6h 
the  virtue  aiud  probity  of  one  or  both  parties  to  the  venereal  act 
may  be  brought  in  question. 

Exciting  Causes.— 1,  Trauma;  2,  bacteria  (non-specific);  3,  tox- 
ins; 4,  chemical  irritation ;  5,  sexual  strain.  It  is  unnecessary  to  ex- 
patiate upon  traumatism  as  a  factor  in  the  production  of  urethritis. 
It  should  be  remembered,  however,  that  traumatism  in  a  perfectly 
healthy  and  approximately  aseptic  urethra  may  be  followed  by  little 
or  no  inflammation ;  often,  indeed,  by  no  phenomena  which  can  be 
properly  characterized  as  urethritis.  In  the  presence,  however,  of 
some  latent  condition  of  disease — i.e.,  a  chronic  source  of  infection, 
traumatism  bears  a  very  important  relation  to  the  etiology  of  acute 
urethritis.  A  very  pertinent  illustration  of  the  relation  of  trauma- 
tism to  pre-existing  conditions  of  infection  of  the  urethra  is  found  in 
the  results  of  operations  or  instrumental  manipulations  of  the  canal 
in  the  presence  of  stricture  or  congested  and  granular  patches  on  the 
urethral  mucous  membrane. 

In  considering  the-  relation  of  bacterial  infection  to  simple  ure- 
thritis, it  is  well  to  remember  the  fact  that  various  forms  of  bacteria 
and  their  products  are  capable  of  producing  irritation  and  inflamma- 
tion of  mucous  membranes.  The  pus  microbe  or  its  derivatives,  and 
possibly  the  ordinary  germs  of  decomposition,  may  per  se,  or  by 
virtue  of  their  products,  produce  urethritis.  The  author  will  not  dis- 
cuss here  the  relation  of  the  bacterium  coli  commune  to  inflamma- 
tions of  the  genito-urinary  tract.  It  appears  highly  probable  that  the 
line  of  demarkation  between  the  pus  microbe  and  the  colon  bacillus 
would  be  very  diflicult  to  demonstrate.  A  point  worthy  of  consid- 
eration is  that  the  secretions  from  disease  of  the  urethra,  originally 
of  gonococcal  origin,  but  from  which  all  specific  characters  have  dis- 
appeared, (as  in  certain  cases  of  chronic  urethritis,  folliculitis  and 
prostatitis  and  in  certain  inflammations  of  the  female  genito-urinary 
tract),  are  capable  of  producing  inflammation  of  the  male  urethra. 
That  the  toxins  evolved  by  microbial  action  may  cause  urethritis  is 
almost  if  not  quite  certain.  Any  chemical  in-itant  may  produce 
urethritis,  which  sometimes  assumes  a  severe  type.  The  well-known 
exijeriment  of  Swediaur  with  aqua  ammonias  will  be  remembered  in 
this  connection. 

In  discussing  the  exciting  causes  of  simple  urethritis  it  is  neces- 
sary to  correct  the  fallacious  notion  that  normal  secretions  in  the 
female  are  cai)able  of  exciting  urethritis  in  the  male.  It  is  nothing 
unusual  for  the  apology  to  be  offered  that  the  man  has  had  inter- 


445  LYDSTON — DISEASES   OP  THE  MALE   UEETHRA. 

course  witli  tlie  woman  just  before,  after,  or  during  tlie  menstrual 
discharge.  Tlie  inference  that  the  menstrual  discharge  may  pro- 
duce urethritis  is  as  old  as  the  Bible,  as  will  be  noted  by  a  perusal 
of  the  fifteenth  chapter  of  Leviticus.  The  Jewish  tradition  that  the 
female  is  unclean  for  a  certain  period  following  menstruation  is  prob- 
ably based  upon  this  common  but  erroneously  applied  observation. 
Menstrual  fluid,  unless  decomposed  or  mixed  with  the  products  of 
bacterial  evolution  of  one  kind  or  another — whether  the  germs  be 
autogenetic  or  heterogenetic  is  inconsequential — cannot  possibly  pro- 
duce urethritis.  Apparent  contradictions  are  due  either  to  the  auto- 
genesis of  urethritis  in  a  previously  damaged  urethra,  or  to  the  wash- 
ing doT\Ti  of  the  products  of  an  old  infection  from  the  iipper  portion  of 
the  female  sexual  tract  by  the  outflowing  menstrual  secretion.  The 
menstrual  secretion  has  been  accepted  as  an  etiological  factor  in 
urethritis;  the  water-closet  theory  has  been  repudiated,  but  the 
author  entertains  the  belief  that  the  latter  theory  has  at  least  a  basis 
of  probability,  while  the  former  is  positively  absurd. 

The  "  strain"  theory  of  the  origin  of  urethritis  is  a  very  x)opular 
one,  but  is  perhaps  the  most  fallacious  of  all.  It  is  probable  that 
sexual  excess  alone  is  never  productive  of  the  disease.  Sexual  excess 
in  the  presence  of  a  diseased  urethra  is,  however,  another  matter 
and  under  such  conditions  is  a  very  important  factor  among  the  ex- 
citing causes  of  urethritis.  As  a  predisposing  factor,  on  the  other 
hand,  it  is  all-important. 

Gonococcal  or  Specific  Ueetheitis. 

Predisposing  Causes. — These  are  precisely  the  same  as  those 
enumerated  for  simple  urethritis. 

Exciting  Causes. — The  author  will  not  enter  into  a  discussion  of 
the  various  arguments  relative  to  the  specificity  of  the  gonococcus. 
It  is  sufficient  to  say  that  certain  types  of  virulent  urethritis  are 
characterized  by  the  presence  of  a  germ  of  peculiar  character— the 
gonococcus — ^which  microbe  may  be  the  cause  or  the  effect  of  the 
disease.  Whether  it  be  the  cause  or  effect,  however,  it  has  been 
conclusively  shown  that  this  microbe  is  capable  of  producing  in  a  per- 
fectly healthy  mucous  membrane  an  inflammation  similar  to  that 
from  which  the  secretion  which  contains  it  was  originally  derived. 

Apropos  of  the  method  of  contagion  in  gonorrhoea,  it  has  seemed 
to  the  author  that  considerable  illogical  reasoning  has  been  indulged 
in  regarding  the  possibility  of  infection  with  gonorrhoea  in  an  inno- 
cent manner.  Syphilis  insontium  is  well  recognized,  but  whenever 
an  individual  presents  himself  with  a  gonorrhoea  and  gives  a  history 


GONOCOCCAL  OR  SPECIFIC  URETHRITIS.  443 

of  unknown  or  innocent  source  of  infection,  the  practitioner  treats 
the  history  with  lofty  disdain  and  a  contempt  born  of  a  profound 
knowledge  of  human  nature,  particularly  as  manifested  in  venereal 
diseases.  The  author  unhesitatingly  affirms  that,  other  things  being 
equal,  gonorrhoea  is  more  likely  to  be  contracted  innocently  than  is 
syphilis.  The  principal  limitation  of  the  application  of  this  state- 
ment is  the  fact  that  the  structures  susceptible  to  gonorrhoea  are  of 
comparatively  small  area  and  not  very  readily  accessible,  whereas 
in  the  case  of  syphilis  any  abraded  surface  will  serve  as  a  port  of 
entry  for  the  germ  disease.  Granted,  however,  the  contact  of  the 
mucous  membrane  with  gonorrhoeal  virus,  infection  very  much  more 
readily  occurs  than  in  the  case  of  syphilis,  the  latter  disease  requiring 
an  abrasion  as  one  of  the  essential  requisites  for  infection.  Granted 
that  the  gonorrhoea  depends  upon  a  very  virulent  germ,  or  even  lay- 
ing the  germ  theory  aside  for  the  moment  and  accepting  the  broad 
proposition  that  gonorrhoea  affords  a  secretion  which  is  extremely 
virulent,  it  only  remains  to  show  that  facilities  for  the  innocent  con- 
veyance of  the  disease  are  of  daily  occurrence  in  order  to  substanti- 
ate the  proposition  that  gonorrhoea  may  possibly  be  frequently  con- 
tracted in  a  perfectly  innocent  manner. 

The  water-closet  theory  of  the  origin  of  gonorrhoea  has  received 
much  ridicule,  yet  the  author  is  inclined  to  the  belief  that  if  logic 
rather  than  ridicule  be  applied  to  a  study  of  the  question,  the  theory 
will  not  appear  quite  so  absurd.  It  is  a  practical  impossibility  for  an 
individual  affected  with  a  gonorrhoea  to  use  the  public  closets  found 
in  saloons  and  hotels  without  leaving  more  or  less  of  the  virulent  dis- 
charge behind  him.  The  meatus  urinarius  is  dragged  over  the  closet 
seat  in  such  a  manner  as  inevitably  to  deposit  more  or  less  secretion, 
unless  the  patient  be  much  more  careful  than  the  average  man.  The 
next  individual  who  uses  the  same  convenience  will  in  the  majority 
of  instances,  unless  extremely  careful,  inevitably  bring  his  meatus 
urinarius  in  contact  with  the  infected  surface.  Is  it  illogical  to  sup- 
pose that  gonorrhoeal  infection  may  occasionally  occur  in  this  man- 
ner? We  are  entirely  too  fond  of  questioning  the  veracity  of  the 
X>atient,  but  ridicule  is  hardly  a  safe  argument  as  apj)lied  to  a  ques- 
tion that  can  be  reasoned  upon  quite  as  logically  as  can  the  subject 
of  infection  of  any  other  kind.  The  author  unhesitatingly  affirms 
that  this  is  important  from  a  medico-legal  standpoint.  The  man  who 
goes  upon  the  witness-stand  and  offers  expert  testimony  to  the  effect 
that  any  individual  might  not  possibly  have  contracted  gonorrhoea  in 
the  innocent  manner  above  described,  must  certainly  depart  from  the 
ordinary  rules  of  logic,  and,  however  profound  his  knowledge  of  bac- 
terial infection  in  other  directions,  must  necessarily  manifest  upon 


444  LYDSTON — DISEASES   OF  THE  MALE  UEETHEA. 

this  question  tlie  densest  ignorance  of  sound  pathological  and  bacte- 
riological principles.  Tlie  same  argument  is  pertinent,  altliougli 
perhaps  not  equally  so,  as  applied  to  possible  innocent  infection  of 
the  female.  The  author  is  well  aware  that  this  statement  is  likely  to 
be  received  with  derision,  but,  as  already  stated,  ridicule  upon  a 
question  so  open  to  logical  reasoning  as  the  one  under  consideration 
is  hardly  worthy  of  respect.  The  possible  medico-legal  application 
of  the  author's  opinion  has  received  due  consideration,  but  has  by  no 
means  weakened  the  conviction  above  outlined. 

Accepting  the  gonococcus  as  the  most  definite  etiological  factor 
that  has  thus  far  been  determined  in  virulent  urethritis,  it  becomes 
necessary  to  consider  its  characteristics.  During  the  last  quarter  of 
a  century  several  authors  have  claimed  to  have  discovered  the  germ 
or  organism  upon  which  the  disease  depends,  but  none  of  their  views 
has  been  generally  accepted  by  the  profession.  The  latest  aspirant 
to  honors  in  the  microscopical  study  of  urethritis  is  Neisser,  of 
Breslau,  who  in  1879  asserted  that  he  had  discovered  the  specific' 
microbe  of  gonorrhoea,  which  he  termed  the  gonococcus.  Numerous 
European  bacteriologists  published  confirmatory  reports  regarding 
this  micro-organism,  and  during  the  last  few  years  several  American 
investigators  have  indorsed  the  views  of  Neisser.  At  the  present 
time  the  majority  of  the  profession  have  accepted  the  specificity  of 
the  gonococcus.  The  alleged  specific  germ  has  been  found  in  the  pus 
corpuscles.  Its  detection  under  the  microscope  was  first  made  pos- 
sible by  certain  complicated  processes  of  staining.  A  little  later,  Drs. 
Wendt  and  Allen,  of  New  York  Citj^,  detected  the  bacillus  in  the 
following  rather  simple  manner:  A  drop  of  pus  is  spread  into  a 
thin  layer  by  pressing  between  two  glass  slides,  and  allowed  to  dry 
in  the  air.  A  drop  of  solution  of  methyl  blue  in  anilin  water  is  now 
placed  upon  it  for  a  moment  and  washed  off  with  a  stream  from  a 
wash-bottle.  A  few  drops  of  Grams'  iodo-iodide  liquid  is  then 
poured  on  and  allowed  to  remain  for  several  minutes ;  this  fixes  the 
color  of  micro-organisms  in  general.  Grams'  liquid  is  now  washed 
off,  and,  while  the  specimen  is  still  wet,  a  cover-glass  is  placed  upon 
it  and  it  is  examined  with  an  oil  immersion  lens.  If  micro-organisms 
resembling  the  gonococcus  are  found,  they  are  tested  by  decoloriza- 
tion.  The  cover-glass  is  removed,  and  the  specimen  treated  with 
absolute  alcohol  until  the  color  is  as  completely  removed  as  possible. 
The  cover-glass  is  replaced,  and  the  specimen  examined,  when  all 
the  gonococci  will  be  found  to  have  disappeared ;  all  other  organisms, 
however,  which  have  been  present  will  be  distinctly  visible. 

The  gonococcus,  as  described  by  Neisser,  was  developed  from  the 
pus  corpuscle  by  staining  with  methyl- violet  and  dahlia.      It  is 


MOEBID  ANATOMY.  445 

located  generally  upon  the  surface  of  the  pus-corpuscle ;  more  rarely 
upon  the  surface  of  the  epithelium.  Sometimes  it  is  incorporated 
with  the  corpuscle  and  replaces  its  nucleus,  which  disappears.  The 
microbe  is  large  and  spherical  when  single ;  in  some  instances  two  of 
them  unite  together  in  a  sort  of  biscuit-shape.  They  are  usually 
found  in  colonies  of  ten  to  twenty  or  more,  surrounded  by  a  kind  of 
mucous  envelopment. 

For  practical  purposes  the  simpler  methods  of  examination  of 
suspected  fluids  are  best.  A  drop  of  j)us,  placed  upon  a  cover-glass, 
may  be  spread  into  a  thin  layer  by  placing  another  glass  upon  it  and 
sliding  the  two  apart.  One  of  the  glasses  is  then  thoroughly  dried  by 
passing  it  rapidly  through  the  flame  of  a  spirit-lamp.  The  cover- 
glass  is  now  dipped  in  a  solution  of  methyl  blue,  and  the  superfluous 
coloring  matter  washed  off  by  a  stream  of  cold  water.  It  should  now 
be  mounted  in  Canada  balsam.  Neisser  has  more  recently  laid  es- 
pecial stress  upon  the  tendency  of  the  gonococci  to  arrange  them- 
selves in  pairs.  This,  he  claims,  distinguishes  them  from  the  ure- 
thrococci,  which  are  found  singly  or  in  irregular  clumps.  He  also 
says  that  the  gonococci  are  found  in  or  upon  the  pus  corpuscle,  never 
outside  of  it.  One  important  source  of  fallacy  at  once  suggests  itself. 
It  is  by  no  means  improbable  that  the  urethrococcus  may  undergo 
modification  by  virtue  of  the  existence  of  a  virulent  inflammatory 
process,  as  a  consequence  of  which  it  tends  to  arrange  itself  some- 
what differently  and  to  invade  the  pus  corpuscles.  This  is  certainly 
consistent  with  the  evolutionary  theory.  Taken  singly,  the  urethro- 
coccus and  gonococcus  are  identical  in  appearance. 

Morbid  Anatomy. 

Inasmuch  as  the  anatomical  features  of  specific  and  simple  urethri- 
tis differ  in  degree  only,  the  morbid  anatomy  of  the  disease  in  general 
may  be  properly  taken  up  at  this  point.  The  infection  of  urethritis 
is  generally  supposed  to  begin  at  the  meatus.  Milton  has  remarked 
the  apparent  contradiction  of  urethral  chancre  and  chancroid  as 
regards  the  site  of  inoculation.  He  believes  that  in  such  cases  the 
virus  is  deposited  at  the  lips  of  the  meatus  and  subsequently  diffuses 
itself  until  it  meets  with  a  susceptible  portion  of  mucous  membrane. 
It  is  a  question  whether  morbid  secretions  may  not  be  drawn  into 
the  urethra  during  coition.  The  author  firmly  believes  that  they  may 
be.  It  would  seem  that  a  certain  amount  of  aspiration  is  produced 
in  the  urethra  during  the  venereal  orgasm,  suflicient  at  least  to  draw 
secretions  from  the  vagina  into  the  urethra.  The  alternate  contrac- 
tion and  relaxation  of  the  deep  perineal  muscles  incidental  to  the 


446  LYDSTON — DISEASES   OF   THE   MALE   UEETHRA. 

efforts  of  the  urethra  to  clear  itself  of  semen  during  the  venereal 
act  must  necessarily  produce  a  more  or  less  marked  suction  at  the 
meatus.  It  is  the  author's  impression  that  the  inflammation  really 
begins  in  the  fossa  navicularis  rather  than  at  the  meatus  proper. 

The  extent  to  which  the  urethra  is  involved  is  variable.  The 
inflammation  is  generally  most  marked  in  the  anterior  portion  of  the 
canal,  but  in  the  severe  types  almost  always  involves  the  entire  canal 
down  to  the  bulbo-membranous  junction  and  in  many  cases  extends  to 
the  posterior  urethra.  The  entire  mucous  membrane  of  the  urethra 
from  the  meatus  to  the  bladder  may  be  infected.  In  the  milder  forms 
of  urethritis  the  pathological  changes  consist  in  a  few  instances  of 
slight  hypergemia  with  attendant  reddening  and  hypersecretion.  In 
by  far  the  majority  of  cases,  however,  there  will  be  found  chronic 
changes  in  the  canal  produced  by  a  pre"\dou8  attack  of  virulent  ure- 
thritis. The  pathological  anatomy  of  simple  acute  urethritis  and 
that  of  chronic  urethritis  are  therefore  usually  identical  and  should 
be  described  simultaneously.  In  simple  urethritis  with  a  chronic 
inflammatory  foundation,  the  localization  of  the  chronic  inflamma- 
tion, with  perhaps  the  formation  of  stricture  or  abraded  granular  and 
congested  patches,  is  due  to  several  causes:  (1)  The  most  impor- 
tant is  the  relative  inelasticity  of  the  portion  of  the  urethra  in- 
volved. This  produces  friction  during  micturition  with  consequent 
localization  of  the  inflammation  at  the  particular  point  affected. 
(2)  Dilatation  and  severe  inflammation  of  mucous  follicles  at  one  or 
more  points  in  the  canal.  (3)  Injury  of  the  canal  at  different  points 
due  to  the  introduction  of  instruments,  the  long-nozzled  syringe  being 
the  most  frequent  cause.  (4)  The  spontaneous  or  traumatic  yielding 
of  the  corpus  spongiosum  in  the  course  of  a  chordee.  (5)  Slight 
thickening  of  the  urethra  due  to  previous  traumatism.  In  cases  in 
which  j)osterior  urethral  infection — prostatitis — has  occurred  in  the 
course  of  acute  gonorrhoea,  more  or  less  enlargement  of  the  organ  is 
found,  together  with  a  varying  degree  of  interstitial  thickening  and 
chronic  inflammation  in  the  prostatic  ducts  and  follicles. 

In  the  severe  forms  of  urethritis  the  principal  change  consists  in 
intense  hyperEemia  with  swelling  of  the  mucous  membrane.  This  is 
attended  by  a  diminution  in  the  calibre  of  the  canal  which  may  re- 
sult in  complete  retention  of  urine.  When  the  inflammation  is  at  its 
height,  there  exists  an  infiltration  of  the  corpus  spongiosum  resulting 
in  thickening  and  inelasticity  of  that  structure.  Late  in  the  history 
of  the  case  this  plastic  infiltration  either  disappears  entirely  or,  as  is 
very  frequent,  localizes  itself  at  certain  points.  These  points  are 
usually  the  posterior  portion  of  the  fossa  navicularis,  the  lacuna  magna, 
■  and  the  bulbo-membranous  junction.  ■  Other  points  in  the  pendulous 


COMPLICATIONS.  447 

urethra  are  frequently  involved.  It  is  in  these  situations  that  we  are 
most  likely  to  find  stricture.  The  follicles  of  the  urethra  are  found 
to  be  dilated  and  filled  with  purulent  or  muco-purulent  secretion. 
Herpetic  excoriations  are  occasionally  seen.  In  view  of  the  severity 
of  the  inflammation  in  some  cases,  it  is  singular  that  true  ulceration 
does  not  more  often  occur.  It  is,  however,  very  rare.  The  epithe- 
lium lining  the  urethra  will  be  found  abraded  here  and  there  in  all 
cases  in  which  the  inflammation  is  of  a  high  grade.  In  some  in- 
stances it  is  almost  entirely  removed  throughout  the  extent  of  the 
canal.  Superficial  erosions  of  the  mucous  membrane  result  from 
abrasion  of  the  epithelium.  In  chronic  cases  the  pathological  factors 
which  are  most  important  as  explaining  the  persistency  of  the  dis- 
ease are  stricture,  congested  and  granular  patches,  enlargement  of 
the  lacuna  magna,  dilatation  and  inflammation  of  the  glands  of  Littre 
and  sinuses  of  Morgagni,  and  follicular  prostatitis — i.e.,  so-called 
posterior  urethritis. 

Complications. 

The  danger  of  complications  in  urethritis  is  directly  propor- 
tionate to  the  severity  of  the  inflammation  and  the  degree  and  fre- 
quency with  which  the  canal  is  mechanically  disturbed.  An  impor- 
tant factor  in  the  etiology  of  complications  is  the  amount  of  exercise 
indulged  in  by  the  patient.  With  reference  to  the  etiology  of  com- 
plications, it  is  to  be  remembered  that  the  gonococcus  is  by  no  means 
the  principal  factor.  Gonorrhcea  is  a  typically  mixed  infection,  and 
many  of  the  most  severe  complications  of  urethritis  are  in  no  wise 
dependent  upon  the  gonococcus  excepting  in  so  far  as  the  gonococcus 
may  have  been  the  original  cause  of  the  urethral  inflammation. 

The  principal  complications  of  urethritis  are :  (1)  Severe  chordee; 
(2)  hemorrhage;  (3)  folliculitis;  (4)  peri-urethral  phlegmon;  (5)  re- 
tention of  urine  from  inflammatory  or  spasmodic  stricture ;  (6)  pros- 
tatitis; (7)  cowperitis;  (8)  cystitis;  (9)  epididymitis  and  orchitis; 
(10)  gonorrhoeal  rheumatism ;  (11)  gonorrhoeal  ophthalmia ;  (12)  gon- 
orrhoeal  conjunctivitis;  (13)  bubo;  (14)  balanitis  and  balano-pos- 
thitis;   (15)  vegetations,  and  (16)   lymphangitis. 

Some  of  these  various  complications  are  worthy  of  special  de- 
scription, but  an  exhaustive  presentation  is  not  practicable  in  a  work 
of  this  kind.  A  few  general  points  regarding  the  most  important  of 
them  are,  however,  essential. 

Chordee. 

Severe  chordee  and  distinct  hemorrhage  are  naturally  associated, 
inasmuch  as   the  latter  depends  ui)on  traumatism  inflicted  in  the 


448  LYDSTON — DISEASES  OF  THE  IiIALE   UEETHEA. 

former  condition.  Cliordee  develops  when  the  inflammation  is  at  its 
maximum  intensity,  at  which  time  the  plastic  exudate  is  most 
marked.  It  gives  rise  to  no  inconvenience  excepting  during  erection. 
The  pain  which  it  produces  is  therefore  usually  experienced  at  night. 
The  penis  during  erection  may  be  bent  like  a  bow,  the  concavity  of 
which  is  directed  downward,  but  in  some  instances  it  may  be  bent 
to  one  or  the  other  side  or  twisted.  The  principal  dangers  of 
chordee  are  rupture  and  hemorrhage  with  subsequent  severe  organic 
stricture  or  perhaps  abscess. 

Folliculitis. 

Localized  and  severe  inflammation  of  the  mucous  follicles  of  the 
urethra  is  likely  to  occur  at  any  time  during  acute  urethritis,  and 
sometimes  in  the  subacute  and  chronic  types.  The  condition  mani- 
fests itself  by  small,  tender,  spheiical,  or  oval  swellings  from  the  size 
of  a  small  shot  to  that  of  a  pea  along  the  floor  of  the  canal,  especially 
anteriorly.  The  condition  is  due  to  an  infection  of  the  urethral  fol- 
licles and  sinuses  of  Morgagni,  resulting  in  the  formation  of  small  re- 
tention cysts  containing  pus  and  mucus.  They  rarely  lead  to  serious 
trouble,  but  usually  discharge  themselves  into  the  urethra.  They 
are  likely,  however,  to  be  the  source  of  recurrent  urethral  infection. 

Peri-Urethral  Phlegmon. 

This  is  a  frequent  complication  of  urethritis.  It  consists  of  an 
inflammation  of  the  cellular  tissue  surrounding  the  urethra,  and  is 
due  to:  (1)  Minute  rupture  of  the  mucous  membrane  with  resulting 
peri-urethral  infection;  (2)  Rupture  of  the  inflamed  and  infected 
follicle  with  a  similar  result ;  (3)  Infection  conveyed  to  the  cellu- 
lar tissue  by  means  of  the  lymphatics,  or  by  migration  of  pyogenic 
microbes ;  (4)  Rupture  and  extravasation  of  the  dilated  and  ulcerated 
urethra  behind  a  stricture.  All  of  these  inflammatory  complications 
imply  either  extension  by  contiguity  of  structure  via  the  mucous 
ducts,  or  an  abrasion  of  epithelium  with  a  resultant  absorptive  surface. 
Phlegmonous  inflammation  usually  leads  to  suppuration,  but  cases 
occur  in  which  resolution  eventually  takes  place.  The  favorite  seat 
of  this  complication  is  in  the  floor  of  the  fossa  navicularis. 

Retention  of  Urine. 

Retention  of  urine  is  essentially  the  same  in  its  various  phases  as 
when  arising  from  other  causes.  It  depends  on  inflammatory  swell- 
ing of  the  mucous  and  submucous  tissues  in  conjunction  with  deep 


ACUTE  PROSTATITIS — COWPERITIS — CYSTITIS.  449 

muscular  spasm.  This  is  the  so-called  congestive  or  inflammatory 
stricture,  and  may  be  precipitated  by  sexual  or  dietetic  excesses  or 
indiscretions. 

Acute  Prostatitis. 
This  has  been  described  in  connection  with  diseases  of  the  prostate. 

COWPERITIS. 

Inflammation  of  Cowper's  glands  occasionally  occurs.  It  is  due  to 
simple  extension  of  the  inflammation  to  these  glands,  which  lie 
upon  either  side  of  the  urethra  behind  the  bulb  and  between  the  lay- 
ers of  the  triangular  ligament.  It  is  usually  unilateral,  but  it  may 
involve  both  sides. 

Symptoms. — The  symptoms  are  pain,  swelling,  throbbing,  and  a 
feeling  of  tension  in  the  perineum.  Early  examination  detects  a 
small  sensitive  tumor  the  size  of  a  pea ;  later  on  the  perineum  be- 
comes swollen,  hard,  and  brawny,  and  it  is  imposible  to  outline  the 
inflamed  gland.  Swelling,  reddening,  and  oedema  of  the  scrotum  may 
occur.  There  is  likely  to  be  considerable  constitutional  disturbance 
incidental  to  the  close  confinement  of  the  inflammatory  exiidate  within 
the  triangular  ligament.  Suppuration  usually  occurs,  but  resolution 
occasionally  takes  place  without  it. 

Cystitis. 

True  acute  cystitis  is  a  rare  complication  of  urethritis.  The 
epithelium  of  the  vesical  mucous  membrane  is  singularly  resistant  to 
gonorrhoeal  infection.  When  it  does  become  infected,  it  is  by  virtue 
of  the  mixed  infection  characteristic  of  gonorrhoea.  The  majority  of 
cases  in  which  acute  gonorrhoeal  cystitis  is  diagnosed  consist  of  acute 
follicular  prostatitis — i.e.,  inflammation  in  and  about  the  true  vesical 
neck.  "When  infection  of  the  bladder  does  occur,  the  resulting  inflam- 
mation may  become  chronic.  Extension  to  the  ureters,  renal  pelvis, 
and  even  the  renal  structure  proper  may  occur.  Rare  cases  of  acute 
general  cystitis  in  the  course  of  gonorrhoea  have  been  reported.  They 
are  characterized  by  profound  asthenia  and  a  typhoid  condition,  with 
dry,  brown  tongue,  delirium,  and  fever,  and  it  is  claimed  sloughing  of 
the  vesical  mucous  membrane  may  occur  in  some  cases. 

Sym/ptoms. — Frequent,  painful,  and  perhaps  bloody  micturition. 
More  or  less  tenderness  of  the  vesical  neck,  as  disclosed  by  palpa- 
tion externally  and  x^er  rectum.  In  severe  general  cases  extreme 
hypogastric  tenderness  exists.  In  some  severe  cases  the  symptoms 
strongly  resemble  those  of  general  peritonitis,  the  abdominal  tender- 
ness and  pain  being  quite  difl'used.  A  certain  degree  of  peritoneal 
Vol.  l.—m 


450  LYDSTON — DISEASES  OF  THE  MALE  URETHRA. 

involvement  is  quite  possible.  Severe  constitutional  symptoms  are 
not  unusual.  Tlie  urine  is  scanty,  high-colored,  and  perhaps  bloody. 
It  contains  albumin  proportionate  in  amount  to  the  quantity  of  pus 
and  blood  present.  If  sloughing  of  the  mucous  membrane  occurs, 
shreds  of  that  structure  are  expelled  with  the  urine.  Clots  may  be 
formed  and  come  away  with  the  urine  during  micturition,  their  ex- 
pulsion being  attended  by  severe  pain  and  tenesmus. 

EprDIDYMITIS  AND   ORCHITIS. 

Inflammation  of  the  testicle  occurring  in  the  course  of  acute  or 
chronic  gonorrhoea  is  very  frequent.  Its  presence  is  usually  an  indi- 
cation of  extension  of  infection  to  the  deep  urethra.  Exceptions  to 
this  rule  are  met  with,  but  the  proposition  is^  accurate  in  its  general 
application.  Like  all  inflammations,  that  of  the  testis  may  be 
acute,  subacute,  or  chronic.  The  afi'ection  may  occur  at  any  time 
during  the  course  of  a  gonorrhoea,  and  indeed  at  times  when  the  pa- 
tient considers  himself  free  from  the  primary  disease.  The  body  of 
the  testis  is  rarely  affected  primarily,  the  condition  being  in  the 
majority  of  cases  one  of  inflammation  of  the  epididymis,  with  per- 
haps more  or  less  secondary  involvement  of  the  testis  proper. 

The  mode  of  infection  is  of  considerable  practical  importance. 
Quite  frequently  the  disease  comes  on  within  a  very  short  time  after 
the  introduction  of  instruments  or  after  the  employment  of  other 
mechanical  methods  of  treatment.  Under  such  circumstances  the 
inflammation  of  the  testis  is  produced  in  one  of  two  ways,  either  (1) 
by  direct  traumatism  and  sepsis  of  the  mucous  membrane  of  the  deep 
urethra  which  eventually  involves  the  ejaculatory  ducts ;  or  (2)  the 
instrument  acts  as  a  carrier  of  infectious  material  into  the  deep 
urethra,  the  germs  of  the  mixed  infection  and  their  products  being, 
as  it  were,  rubbed  into  the  mouths  of  the  ejaculatory  ducts.  The 
prostatic  follicles  are  usually  involved,  although  they  may  apparently 
escape  for  a  time  at  least.  In  a  general  way,  the  existence  of  epi- 
didymitis may  be  accepted  as  positive  evidence  of  infection  of  the 
prostate.  It  is  probable  that  in  some  cases  infection  occurs  from  the 
deeper  parts  into  the  urethra  via  the  lymphatics,  without  the  inter- 
vention of  deep  urethral  inflammation.  As  a  consequence  of  sexual 
indulgence,  or  without  known  exciting  cause,  inflammation  of  the 
epididymis  very  frequently  occurs.  It  is  the  impression  of  the  author 
that  the  sexual  orgasm  is  very  often  responsible  for  infection  of  the 
deeper  parts  of  the  urethra  by  virtue  of  the  aspirating  action  of 
the  deep  urethral  muscles  during  seminal  emission.  It  appears  logical 
to  infer  that  infectious  materials  may  be  drawn  from  the  anterior  into 


EPrDIDYMITIS  AOT)  ORCHITIS.  451 

the  posterior  urethra  during  the  venereal  act.  The  rationale  of  this 
accident  has  been  considered  elsewhere.  The  old-time  view  of  metas- 
tasis of  the  urethral  inflammation  would  appear  to  be  no  longer 
tenable.  It  must  be  confessed,  however,  that  the  clinical  features  of 
epididymitis  occurring  in  the  course  of  acute  gonorrhoea  afford  some 
support  to  the  old-fashioned  notions  regarding  metastatic  inflamma- 
tion. The  subsidence  of  the  urethral  discharge  and  its  reappearance 
coincidentally  with  improvement  in  the  testicular  inflammation  con- 
stitute a  very  striking  feature  of  this  particular  complication  of  gon- 
orrhoea, and  one  which  must  have  appealed  very  forcibly  to  our  medi- 
cal forefathers  as  substantiating  the  theory  of  metastasis. 

Symptoms. — It  is  very  exceptional  that  testicular  complications 
occur  within  the  first  week  of  a  gonorrhoea.  As  a  rule,  the  epididy- 
mis is  not  involved  under  ten  days  or  two  weeks.  Inasmuch  as  the 
inflammation  gradually  progresses  toward  the  deeper  parts  of  the 
urethra,  this  fact  is  readily  understood.  In  some  instances  the  attack 
is  precipitated  by  sexual  or  alcoholic  indulgence,  or  over-exertion. 
Very  often,  as  already  stated,  the  patient  presents  a  history  of  instru- 
mental interference  with  the  deep  urethra.  In  chronic  cases  the 
epididymis  may  become  involved  at  any  time,  often  indeed  when  the 
patient  supposes  himself  perfectly  free  from  urethral  discharge.  Its 
occurrence  under  such  circumstances  is  positive  evidence  of  urethral 
infection.  Stricture  of  the  urethra  is  especially  apt  to  be  complicated 
from  time  to  time  by  attacks  of  epididymitis.  It  is  likely  in  these 
chronic  cases  of  urethral  disease  to  assume  a  subacute  or  chronic  type. 

The  symptoms  vary  with  the  acuteness  of  the  disease.  In  the 
acute  cases  two  methods  of  invasion  are  observed.  (1)  Those  in 
which  the  patient  is  primarily  taken  with  a  severe  pain  in  one  or 
the  other  groin,  referable  to  the  region  of  the  spermatic  cord.  Great 
tenderness  exists  in  this  region.  Symptoms  of  tissue  strangulation, 
similar  to  those  existing  in  hernia,  may  be  observed,  with  slight  nau- 
sea and  vomiting.  The  author  has  in  several  instances  been  called  in 
to  operate  on  strangulated  hernia  and  found  inflammation  of  the 
spermatic  cord,  heralding  an  approaching  epididymitis.  Whenever 
this  condition  exists,  the  patient  may  be  confidently  informed  that 
within  twelve  to  thirty-six  hours  inflammation  of  the  epididymis  will 
develop.  The  reason  for  the  severity  of  the  symptoms  is  a  very  sim- 
ple one.  The  spermatic  cord  is  invested  by  dense  fascial  tendinous 
and  muscular  envelopments,  especially  in  the  vicinity  of  the  external 
ring.  It  is  by  no  means  surprising,  therefore,  that  the  sensitive  cord 
should  be  more  or  less  strangulated  when  it  is  affected  by  acute  in- 
flammation. It  is  the  opinion  of  the  author  that  more  or  less  pelvic 
peritonitis  of  that  x^ortion  of  the  peritoneum  which  invests  the  sper- 


452  LYDSTON — DISEASES  OP  THE   MALE  UKETHEA. 

matic  cord  within  the  pelvis  is  a  quite  constant  feature  of  cases  of  in- 
flammation of  the  testicle  in  which  the  cord  is  involved  in  the  manner 
described.  Cases  occasionally  occur  in  which  acute  appendicitis  is 
quite  closely  simulated.  The  cases  in  which  the  cord  is  especially 
involved  are  usually  very  slow  in  recovering.  Relapses  are  more 
frequent  than  when  the  inflammation  primarily  affects  the  epididy- 
mis. (2)  Cases  in  which  the  epididymis  is  primarily  involved  and 
the  cord  only  secondarily  and  in  a  minor  degree.  The  patient  is 
likely  to  feel  more  or  less  tenderness  and  weight  with  a  peculiar  drag- 
ging sensation  along  the  spermatic  cord  for  a  few  days  or  few  hours 
before  the  inflammation  of  the  epididymis  develops.  The  testis  may 
be  extremely  hyperaesthetic.  The  tenderness  increases  until  the  in- 
flammation is  at  its  maximum,  when  the  slightest  touch  produces 
extreme  pain.  If  the  case  be  examined  before  marked  swelling  oc- 
curs, a  little  swelling  and  tenderness  limited  to  the  epididymis  and 
that  portion  of  the  spermatic  cord  immediately  adjacent  to  the  testis 
will  be  observed.  As  the  inflammation  progresses  the  scrotum  be- 
comes oedematous,  reddened,  and  tender.  The  urethral  discharge 
diminishes,  and  in  many  cases  entirely  subsides.  Milton's  conclu- 
sions regarding  this  particular  symptom  in  epididymitis  are  some- 
what extraordinary.  He  makes  the  assertion  that  marked  subsidence 
or  disappearance  of  the  discharge  is  not  observed  in  epididymitis. 
If  this  be  true  of  Mr.  Milton's  cases,  great  allowance  must  be  made 
for  a  variation  in  the  phenomena  presented  by  patients  in  different 
localities.  As  far  as  the  observations  of  most  surgeons  go,  this  point 
is  so  well  established  that  it  is  hardly  open  to  argument.  When  the 
inflammation  is  weU.  advanced  more  or  less  fluid  will  be  found  in  the 
cavity  of  the  tunica  vaginalis— acute  hydrocele.  The  acute  symptoms 
persist  for  from  five  or  six  days  to  a  week,  and  are  attended  by  more 
or  less  febrile  disturbance.  In  some  cases  there  appears  to  be  marked 
distvirbance  of  digestion ;  the  patient  loses  appetite ;  the  tongue  be- 
comes heavily  furred,  and  constipation  ensues.  When  the  cord  is 
more  or  less  strangulated,  considerable  anxiety  is  manifested.  At  the 
end  of  from  five  to  seven  days  the  inflammation  begins  to  subside ; 
tenderness  diminishes  and  eventually  disappears,  but  when  allowed  to 
take  its  own  course  the  testicle  does  not  return  to  even  approximately 
normal  size  for  some  weeks.  When  suitable  after-treatment  is  not 
instituted,  and  often  in  spite  of  the  greatest  after-care,  permanent 
induration  of  the  epididymis  is  likely  to  result.  Whenever  such 
permanent  induration  exists,  occlusion  of  the  lumen  of  the  epididymis 
may  be  suspected,  and  when  double  epididymitis  has  occurred  and 
the  patient  appears  to  be  sterile,  the  old-time  inflammation  of  the 
epididymis  assumes  a  rather   formidable   character.      Suppuration 


GONOBRHCEAL  RHEUMATISM.  453 

very  rarely  occurs;  when  it  does  do  so,  it  may  be  due  either  to 
tubercular  or  to  purulent  infection.  It  is  worthy  of  note  in  this  con- 
nection that  inflammation  of  the  epididymis  is  apparently  due  to 
the  mixed  character  of  the  gonorrhoeal  infection  rather  than  to  the 
gonococcus  per  se. 

Toxic  pseudo-alkaloids  have  been  extracted  from  gonorrhoeal  pus 
which,  inoculated  into  the  epididymis  of  dogs,  have  produced  charac- 
teristic inflammation. 

GONORRHCEAL   RHEUMATISM. 

Gonorrhoeal  rheumatism  is  an  important,  although  relatively  in- 
frequent, complication  or  sequela  of  gonorrhoea.  The  possibility  of 
its  occurrence  is  disputed  by  some  surgeons,  but  the  majority  of 
authorities  admit  that  some  individuals,  who  are  perhaps  free  from 
predisposition  to  ordinary  rheumatic  troubles,  are  attacked  with 
severe  pain  and  tenderness  of  one  or  several  articulations,  attended 
with  more  or  less  constitutional  disturbance  and  synovial  effusion,  in 
the  course  of  urethritis,  and  that  in  others  the  same  process  attacks 
various  tendinous  and  ligamentous  structures  of  the  body.  Some 
patients'  are  affected  with  this  complication  with  every  attack  of 
urethritis.  It  rarely  begins  during  the  acute  stage  of  the  affection, 
being  most  likely  to  occur  after  the  disease  has  become  chronic. 
The  writer  has  known  it  to  occur,  however,  within  three  days  after 
the  onset  of  the  disease.  Few  diseases  have  been  the  source  of  more 
controversy  regarding  their  origin  than  has  gonorrhoeal  rheumatism, 
and  as  yet  its  i)athology  must  be  regarded  as  subjudice.  It  does  not 
appear  to  arise  as  a  consequence  of  varying  atmospheric  conditions, 
from  over-exertion,  nor,  it  is  claimed,  from  any  particular  method  of 
treatment  of  urethritis.  .The  latter  proposition,  however,  the  author 
is  inclined  to  question,  from  practical  experience  with  the  disease,  espe- 
cially in  a  case  which  recently  came  under  observation,  in  which  the 
rheumatic  affection  speedily  followed  successful  abortive  treatment. 
Its  dependence  upon  purulent  inflammation  of  the  urethra  is  all  that 
has  so  far  been  absolutely  established,  and  it  is  by  no  means  necessary 
that  actual  suppuration  of  the  mucous  membrane  should  be  present 
in  order  to  give  rise  to  it.  It  is  claimed  that,  inasmuch  as  it  occurs 
indej^endently  of  the  ordinary  predisposing  and  exciting  causes  of 
rheumatism,  and  is  seen  in  only  a  small  proportion  of  the  subjects 
of  urethritis,  it  must  necessarily  be  the  result  of  individual  idiosyn- 
crasy.    There  is  7)robably  much  truth  in  this  assertion. 

The  most  generally  accepted  oi)inion  in  regard  to  the  pathology  of 
gonorrhoeal  rheumatism  is  that  it  is  a  mild  sort  of  pyseraic  infection,  due 
to  absor])tion  of  the  ])roductH  of  purulent  inflammation  of  the  urethral 


454  LYDSTON — DISEASES  OP  THE  MALE  URETHRA. 

mucous  membrane.  There  is  hardly  a  doubt  of  the  correctness  of 
this  view ;  still,  as  might  be  supposed,  it  would  be  difficult  to  posi- 
tively prove  it.  According  to  Neisser  and  others  the  disease  is  due  to 
secondary  infection,  the  specific  germ  being  said  to  have  been  found  in 
the  fluid  of  gonorrhoeal  arthritic  effusions.  It  is  well-nigh  certain 
that  some  poisonous  material — toxin — elaborated  by  the  virulent 
germ  infection  of  the  urethral  mucous  membrane,  is  absorbed  into 
the  circulation  and  conveyed  to  the  joint  structures.  In  some  indi- 
viduals these  tissues  are  extraordinarily  sensitive,  and  as  a  conse- 
quence reaction  occurs  in  the  form  of  arthritic  effusion.  Whether  the 
gonococcus  or  the  toxins  formed  by  the  mixed  infection  be  the  exciting 
cause  of  the  affection,  is  open  to  question ;  the  author  inclines  to  the 
latter  cause.  It  is  probable  that  pus  microbes  are  at  the  bottom  of 
those  exceptional  cases  in  which  suppuration  occurs,  and  that  certain 
elements  in  the  surgical  treatment  of  gonorrhoea  are  primarily  re- 
sponsible for  the  absorption  of  infectious  materials.  The  destructive 
effect  exerted  by  strong  injections  and  the  rude  introduction  of  in- 
struments upon  the  epithelium  covering  the  urethral  mucous  mem- 
brane has  already  been  alluded  io.  When  the  mucous  membrane  is 
abraded,  or,  as  is  often  the  case,  almost  entirely  removed,  it  is  ob- 
vious that  the  absorption  of  organic  poisons  is  greatly  facilitated. 
Absorption  probably  does  not  occur  very  readily  through  the  intact 
mucous  membrane,  even  when  it  is  severely  inflamed.  When  once 
the  epithelium  is  destroyed,  however,  it  may  easily  occur.  It  is 
probable  that  the  relative  facility  of  absorption  in  certain  individuals 
explains  their  susceptibility  to  gonorrhoeal  rheumatism,  and  the 
escape  of  others  who  are  more  fortunate.  The  immunity  from  the 
disease  enjoyed  by  women  is  an  evidence  of  the  correctness  of  this 
view,  for  the  only  possible  explanation  of  the  rarity  of  the  disease  in 
the  female  that  can  be  offered  is  that  the  relatively  tough  vagina  and 
endometrium,  and  not  the  urethra,  are  the  seat  of  the  gonorrhoeal 
inflammation,  and  as  a  consequence  absorption  does  not  readily  occur. 
It  will  be  found  that  when  it  does  occur  in  the  female  a  typically 
virulent  and  acute  vaginitis  has  existed  and  has  extended  into 
the  urethra  and  bladder.  The  rheumatism  does  not  usually  follow 
primarily  simple  urethritis,  and  this  shows  that  the  severity  of  the 
virulent  form  of  the  gonorrhoea  bears  a  certain  causal  relation  to  its 
arthritic  complications. 

There  is  a  question  in  the  mind  of  the  author  whether  gonorrhoeal 
rheumatism  is  always  due  to  specific  properties  of  the  poison  of  viru- 
lent urethritis,  as  the  disease  arises  in  cases  in  which,  so  far  as  can 
be  learned  upon  examination  of  the  suspected  party,  and  from  a  mi- 
croscopical study  of  the  discharge,  there  is  no  reason  to  believe  the 


GONORRHCEAL   RHEUMATISM.  455 

origin  of  the  disease  to  have  been  of  a  virulent  character.  Under  such 
circumstances  the  severity  of  the  purulent  process  is  as  marked  as 
though  the  origin  of  the  disease  were  indubitably  virulent  infection. 
Some  cases  are  probably  due  to  mixed  infection. 

It  is  probable  that  cachectic,  strumous,  gouty,  and  rheumatic  pa- 
tients have  a  more  pronounced  predisposition  to  the  disease  than  per- 
sons who  are  perfectly  healthy. 

Symptoms. — The  symptoms  of  the  disease  resemble  those  of  rheu- 
matic gout  rather  than  the  ordinary  form  of  articular  rheumatism. 
As  a  rule,  the  local  evidences  of  the  disease  are  not  severe,  and  con- 
sequently the  constitutional  symptoms  are  comparatively  mild,  but 
this  is  not  always  true.  The  disease  develops,  as  a  rule,  during  the 
decreasing  stage,  and  sometimes  occurs  during  the  second  or  third 
month.  Some  authorities  claim  that  it  occurs  in  from  five  or  six  to 
sixteen  days,  but  in  most  of  the  cases  observed  by  the  author  it  has 
occurred  later  in  the  course  of  the  disease.  The  explanation  that  sug- 
gests itself  is  that  the  inflammatory  thickening  of  the  urethra  inhibits 
to  a  certain  extent  absorption  from  the  surface  of  the  mucous  mem- 
brane. Then,  too,  abrasion  and  removal  of  the  epithelium  are  not 
so  apt  to  occur  within  the  first  few  days  as  later  on,  when  the  poison- 
ous material  has  been  in  contact  with  it  for  some  time.  The  products 
of  the  purulent  process  are  not  so  virulent  in  the  first  few  days  as 
later  in  the  course  of  the  disease. 

There  is  usually  neither  diminution  nor  increase  of  the  urethral 
discharge  coincidentally  with  the  development  of  the  rheumatism; 
rarely  it  is  lessened,  most  probably  because  the  patient  keeps  quiet 
after  the  development  of  joint  complications,  and  this  in  itself  is 
likely  to  benefit  the  urethritis.  It  is  doubtful  whether  gonorrhoeal 
rheumatism  acts  as  a  revulsive  or  derivative  upon  the  inflammation 
of  the  urethra.  It  is  said  that,  when  the  rheumatism  comes  on  late 
in  the  course  of  gonorrhoea,  there  is  liable  to  be  an  increased  discharge 
for  a  few  days.  In  this  matter  iAiQ  propter  and  post  are  probably  con- 
founded; it  is  more  probable  that  from  some  particular  cause  ex- 
acerbation of  the  urethritis  occurs  with  a  coincident  rapid  formation 
of  its  characteristic  toxic  principles;  the  mucous  membrane  of  the 
urethra  being  extensively  abraded  at  this  time,  absorption  readily 
occurs  and  produces  arthritis  or  other  rheumatic  symptoms. 

The  location  of  gonorrhoeal  rheumatism  varies  in  different  indi- 
viduals, and  sometimes  in  the  same  patient  in  different  attacks. 

The  structures  involved,  in  the  order  of  frequency,  are :  (1)  artic- 
ulations ;  (2)  the  synovial  thecss  of  tendons  and  muscles ;  (3)  syno- 
vial bursse  and  the  sheaths  of  nerves.  Associated  with  the  latter  form 
we  may  meet  with   inflammation  of  the   pericardium,  the  cerebral 


456  LYDSTON— DISEASES   OF  THE   MALE  URETHRA. 

meninges,  and  the  deeper  structures  of  the  eye.  The  author  has  seen 
several  cases  in  which  the  eye  alone  was  involved  (gonorrhoeal  des- 
cemetitis) .  A  marked  predilection  is  exhibited  for  the  more  impor- 
tant joints,  the  knee  being  perhaps  most  often  affected.  As  a  rule, 
the  inflammation  expends  most  of  its  violence  upon  one  joint,  al- 
though in  perhaps  the  larger  proportion  of  cases  several  joints  are 
eventually  affected. 

Varieties. — ^Fournier  presents  a  classification  involving  three  dis- 
tinct varieties  of  the  disease,  as  follows : 

1.  Generally  monoarticular  inflammation,  most  often  attacking 
the  knee,  occasionally  the  ankle  or  elbow.  This  form  is  really  a 
passive  hydrarthrosis  with  much  effusion,  characterized  by  very  in- 
sidious development.  Pain,  tenderness,  redness,  heat,  and  constitu- 
tional disturbance  are  either  absent  or  very  moderate.  Resolution 
takes  place  very  gradually,  and  it  is  usually  some  months  before 
recovery  can  be  said  to  be  complete ;  but  even  in  these  cases  ankylosis 
may  occur.  In  some  instances  the  mono-articular  form  is  excessively 
painful,  is  attended  by  marked  constitutional  disturbance,  and  tends 
to  affect  secondarily  the  bones  entering  into  the  formation  of  the 
articulation.  The  fluid  in  such  cases  is  apt  to  contain  more  or  less 
purulent  material,  strongly  resembling  that  which  is  discharged  from 
the  urethra. 

2.  A  variety  not  unlike  articular  rheumatism.  This  is  accom- 
panied by  a  moderate  amount  of  local  and  constitutional  reaction. 
Several  of  the  joints  are  usually  involved,  and  very  often  the  tendons, 
various  other  fibroid  structures,  and  the  eye  are  implicated.  The 
symptoms  are  not  so  severe  as  in  acute  rheumatism,  and  generall}^ 
reaction  is  very  mild  as  contrasted  with  the  magnitude  of  the  joint 
and  other  difficulties. 

The  disproportion  between  general  and  local  symptoms  is  an  im- 
portant point  in  differential  diagnosis.  The  involvement  of  the  joints 
is  usually  consecutive,  but  there  is  none  of  the  articular  delitescence 
characteristic  of  acute  rheumatism.  Profuse  sweating,  acid  urine,  and 
excessive  plasticity  of  the  blood,  which  are  so  characteristic  of  inflam- 
matory rheumatism,  are  usually  absent  in  the  gonorrhoeal  variety. 
The  serous  membranes,  such  as  the  pleura,  endocardium,  and  peri- 
cardium, are  not  often  attacked.  A  favorable  result  generally  occurs, 
but  chronic  synovitis,  strumous  arthritis  in  certain  subjects,  joint 
stiffness  and  complete  ankylosis  are  possible  sequelae.  Fournier 
claims  that  acute  suppuration  does  not  occur  in  gonorrhoeal  rheuma- 
tism ;  some  other  authorities  say  that  it  is  occasionally  seen.  The 
author  believes  that  a  joint  may  contain  a  moderate  amount  of  puru- 
lent fluid  and  still  go  on  to  a  favorable  issue  without  radical  surgical 


GONORRHCEAL  RHEUMATISM.  457 

interference,  whicli  is  not  apt  to  l3e  the  case  with  ordinary  suppura- 
tive arthritis. 

That  suppurative  arthritis  may  occur  as  a  complication  of  gonor- 
rhoea, the  author  is  convinced  from  experience. 

3.  (a)  This  form  consists  in  indeterminate  transitory  pains  in 
various  joints  without  any  local  or  general  evidences  of  disease.  In 
such  cases  there  is  apt  to  be  an  exacerbation  of  the  jjain,  and  perhaps 
a  distinct  involvement  of  the  joint  coincidentally  with  increase  in  the 
urethral  inflammation,  {h)  Thecitis  occurs,  the  synovial  sheaths 
become  swollen  and  and  somewhat  tender,  there  being  moderate  red- 
ness along  the  affected  tendon  in  some  cases.  Movement  of  the 
muscle  attached  to  the  tendon  is  very  painful.  The  synovial  bursse 
may  become  involved ;  the  one  lying  under  the  tendo  Achillis  and 
another  beneath  the  inferior  tubrosity  of  the  os  calcis  are  most 
usually  implicated.  Patients  thus  affected  complain  of  pain  and  ten- 
derness in  the  heel.  This  particular  symptom  is  not  unusual  in  the 
course  of  gonorrhoea.  Myalgia,  resembling  the  ordinary  form,  and 
peri-neuritis  sometimes  occur  in  the  course  of  gonorrhoea,  and  seem 
to  be  attributable  in  certain  instances  to  the  same  pathological  con- 
dition which  gives  rise  to  ordinary  gonorrhoeal  rheumatism.  Pain  in 
the  back,  of  a  severe  character,  simulating  acute  lumbago,  is  very 
frequently  seen;  in  the  majority  of  instances  this  is  due  to  over-stim- 
ulation of  the  kidneys  by  various  balsamic  preparations,  sandalwood 
being  particularly  apt  to  produce  it.  It  does  occur,  however,  in  pa- 
tients who  have  not  taken  such  drugs.  Whether  reflex  neuralgia 
would  explain  these  cases  is  open  to  question. 

Cases  are  occasionally  seen  in  which  gonorrhoeal  rheumatism 
limits  itself  to  a  single  nerve.  One  of  the  author's  patients  has  an 
attack  of  sciatica  coincidentally  with  every  attack  of  gonorrhoea. 
Attacks  of  simple  urethritis  are  sufficient  to  bring  it  on  in  his 
case.  The  first  attack  of  gonorrhoea  which  he  ever  experienced  was 
attended  by  sciatica  of  a  very  severe  character,  both  nerves  being 
involved. 

It  is  somewhat  remarkable  that  authorities  so  universally  con- 
cede the  comparative  painlessness  of  gonorrhoeal  rheumatic  pro- 
cesses when,  as  a  matter  of  fact,  quite  a  liberal  proportion  of  cases  are 
attended  by  severe  pain,  and  not  infrequently  by  sweats  quite  as  pro- 
fuse as  those  which  attend  ordinary  rheumatic  fever.  The  tendency 
to  sweating  seems  to  be  most  marked  at  night,  the  only  difference  be- 
tween the  persi)iration  in  these  cases  and  that  of  ordinary  rheumatism 
being  the  absence  of  acidity,  its  more  prostrating  character,  and  its 
greater  profuseness. 


458  lydston — diseases  op  the  male  urethra. 

Ocular  Complications. 

Tlie  ocular  complications  of  gonorrhoea  necessarily  come  under 
the  province  of  the  ophthalmologist,  yet  inasmuch  as  they  are  apt  to 
be  primarily  presented  to  the  general  practitioner,  it  is  proper  to  devote 
a  little  attention  to  them.  There  are  two  forms  of  ocular  complica- 
tion occurring  in  the  course  of  gonorrhoea,  one  of  which  is  due  to 
local  infection  of  the  conjunctiva  and  the  other  to  the  same  constitu- 
tional impression  that  gives  rise  to  gonorrhoeal  rheumatism. 

As  regards  the  prognosis  of  the  two  affections  there  exists  the 
widest  difference,  the  local  infection  resulting  in  a  large  proportion 
of  cases  in  destruction  of  the  eye,  while  the  constitutional  difficulty 
is  rarely  productive  of  serious  results. 

Gonorrhoeal  ophthalmia,  or  the  form  due  to  the  constitutional  im- 
pression of  a  gonorrhoea,  is  of  a  distinctly  rheumatic  type.  It  is 
well  known  that  persons  affected  with  the  ordinary  form  of  rheuma- 
tism, or  those  who  are  afflicted  with  the  rheumatic  diathesis,  are 
peculiarly  predisposed  to  inflammation  of  the  conjunctival  mucous 
membrane,  and  very  often  of  the  iris.  In  this  respect  gonorrhoeal 
rheumatism  is  like  the  ordinary  form.  Rarely,  however,  does  defi- 
nite iritis  occur,  and  in  several  cases  which  have  come  under  the 
author's  observation  the  implication  of  the  iris  seem  to  be  a  coinci- 
dence rather  than  a  condition  secondary  to  the  gonorrhoea. 

According  to  some  authorities  gonorrhoeal  ophthalmia  is  most 
often  associated  with  involvement  of  the  joints,  particularly  when 
polyarticular.  As  far  as  the  author's  experience  goes,  however,  the 
ocular  complication  have  appeared  to  occur  in  the  majority  of  in- 
stances independently  of  rheumatic  symptoms  in  other  situations. 
The  inflammation  may  attack  the  conjunctiva,  but  more  often 
affects  the  membrane  of  Descemet,  producing  the  condition  known 
as  descemetitis  or  aquocapsulitis.  This  is  characterized  by  its 
insidiousness  of  onset,  the  pain  at  the  beginning  being  comparatively 
trifling.  Later  on,  however,  as  a  consequence  of  mechanical  disten- 
tion of  the  anterior  chamber  of  the  ey&,  there  may  be  considerable 
pain,  varying  with  the  amount  of  increase  in  the  aqueous  humor.  In 
several  instances  coming  under  the  author's  observation  there  was 
more  or  less  involvement  of  the  iris,  assuming  the  form  of  serous  iritis, 
in  which  the  effusion  was  extensive,  giving  rise  to  intolerable  pain 
relieved  only  by  paracentesis.  The  conjunctiva  is  usually  only  mod- 
erately reddened,  lachrymation  being  considerably  increased.  The 
function  of  the  eye  is  disturbed  but  slightly,  objects  having  a  some- 
what cloudy  or  smoky  appearance.  Hemorrhagic  effusion  in  the 
anterior  chamber  has  been  described.     As  a  consequence  of  serous 


BTJBO.  459 

effusion,  the  cornea  becomes  bulging  and  prominent,  and  pari  passu 
with  the  increase  in  this  corneal  bulging  the  pain  becomes  more 
severe. 

A  form  of  catarrhal  conjunctivitis,  secondary  to  urethritis,  is  de- 
scribed by  Fournier,  and  is  supposed  by  him  to  occur  independently 
of  contagion.  It  is  probable  that  such  cases  occasionally  occur,  al- 
though it  would  be  difficult  to  exclude  the  possibility  of  mild  infec- 
tion. Reasoning  from  the  effects  of  ordinary  rheumatism  upon  the 
conjunctiva,  it  is  reasonable  to  suppose  that  a  similar  catarrhal  condi- 
tion of  the  mucous  membrane  might  result  from  gonorrhoeal  rheuma- 
tism. It  is  easily  conceivable  that  the  contraction  of  a  coryza  during 
the  existence  of  rheumatic  irritation  of  the  structures  of  the  eye  in 
the  course  of  a  urethritis  might  readily  result  in  the  production  of 
gonorrhoeal  conjunctivitis. 

Both  eyes  may  be  attacked  in  gonorrhoeal  ophthalmia,  usually 
consecutively,  simultaneous  involvement  being  the  exception  rather 
than  the  rule.  The  prognosis  is  generally  favorable,  although, 
when  iritis  is  a  prominent  factor  in  the  case,  synechige,  with  conse- 
quent disturbance  of  the  functions  of  the  iris,  may  result.  It  is 
possible,  moreover,  that  complete  occlusion  of  the  pupil  by  in- 
flammatory lymph  may  occur. 

Gonorrliceal  conjunctivitis  is  a  far  more  serious  condition  than 
that  which  has  just  been  considered,  and  is  due  to  infection  of  the 
conjunctiva  with  the  irritating  products  of  a  virulent  urethritis.  It 
is  in  no  way  different  from  ordinary  purulent  ophthalmia  of  a  non- 
venereal  type,  unless,  perhaps,  it  be  more  serious  upon  the  average 
and  more  highly  infectious.  Its  prognosis  in  the  majority  of  in- 
stances is  unfavorable.  As  the  disease  belongs  more  properly  to  the 
department  of  ophthalmology,  it  is  unnecessary  to  do  more  than  to 
allude  to  it  as  one  of  the  possible  and  lamentable  complications  of 
urethritis.  The  danger  of  conveying  infection  to  the  eye  T^y  towels 
or  the  fingers  should  be  impressed  upon  the  patient  by  his  medical 
adviser. 

Bubo. 

Urethritis  is  occasionally  complicated  by  bubo.  As  a  rule,  the 
glands  enlarge  but  slightly  and  are  only  moderately  tender.  A  mod- 
erate degree  of  tenderness  in  the  groins,  accompanied  by  little,  if 
any,  enlargement  of  the  inguinal  glands,  is  quite  frequent  in  severe 
cases.  The  enlargement  of  the  glands  may  increase  until  a  pro- 
nounced inflammatory  bubo  develops.  This  is  the  variety  of  bubo 
formerly  known  as  sympathetic.  It  is  due  in  every  instance  to  sec- 
ondary lymphatic  infection  by  i>us  microlxis.     Suppuration  is  un- 


460  LYDSTON — DISEASES   OF  THE  MALE  UEETHRA. 

usual,  or  at  least  pus  rarely  forms  in  sufficient  quantity  to  produce  a 
distinct  abscess.  It  is  the  author's  opinion,  however,  that  in  many 
cases  in  which  a  distinct  bubo  forms,  but  resolves  without  the  for- 
mation of  a  clearly  defined  abscess,  minute  foci  of  suppuration  exist 
throughout  the  gland  structure.  This  assertion  is  based  upon  the 
appearance  of  a  number  of  cases  of  this  kind  in  which  the  glands 
have  been  extirpated.  The  foci  of  suppuration  are  chiefly  distrib- 
uted in  the  periphery  of  the  gland.  When  one  or  more  of  these  foci 
rupture  externally,  peri-adenitis  and  phlegmonous  abscess  develop. 
Suppuration  is  most  apt  to  occur  in  strumous,  tuberculous,  or  other- 
wise cachectic  subjects.  Patients  recently  syphilized  are  also  liable 
to  pus  formation  in  the  affected  glands.  Trauma  or  straining  efforts 
in  lifting  and  over-exertion  of  any  kind  appear  to  have  some  influence 
in  determining  the  occurrence  of  bubo. 

Balanitis  and  Balano-Posthitis. 

Inflammation  of  the  mucous  membrane  of  the  glans  penis — ^bala- 
nitis— and  of  the  preputial  reflexion — posthitis — are  frequent  compli- 
cations of  gonorrhoea.  The  two  conditions  are  usually  associated — 
balano-posthitis.  These  conditions  are  due  to  irritation  produced  by 
retained  and  decomposing  secretions — usually  beneath  a  tight  and 
elongated  prepuce,  although  this  is  not  absolutely  necessary. 

Pus  forms  upon  the  inflamed  surface,  which  becomes  reddened, 
tender,  and  excoriated  from  maceration  and  removal  of  its  epithelium. 
Ulcerations  of  an  herpetic  or  chancroidal  character  may  be  formed.  It 
is  the  author's  opinion  that  typical  chancroid  may  be  developed  de 
novo  under  a  tight  and  inflamed  prepuce.  Bubo  may  result  from  the 
balanitis  rather  than  from  the  gonorrhoea  on  which  the  latter  depends. 

Vegetations. 

As  a  result  of  prolonged  irritation,  combined  with  some  peculiar 
instability  of  local  nutrition — or  tropho-neurosis — some  patients  de- 
velop) fungoid  growths  upon  the  mucous  membrane  of  the  glans  and 
prepuce.  These  are  composed  of  heaped-up  epithelium,  covering 
delicate,  capillary,  vascular  loops.  They  are  very  fragile,  painless, 
and  bleed  readily.  They  resemble  the  vegetable  fungi  in  that  their 
development  is  favored  by  heat,  moisture,  darkness,  and  filth.  They 
are  not  unlike  a  cauliflower  in  their  physical  appearance.  When 
the  conditions  favoring  their  growth  are  perpetuated,  they  sometimes 
attain  an  enormous  size.  They  are  especially  likely  to  develop  in 
women.  They  may  undergo  transformation  into  hyperplastic  tumors, 
particularly  in  women.     The  term  venereal  vegetations,  oftentimes 


TREATMENT.  461 

applied  to  these  growths,  is  a  misnomer,  as  they  are  in  no  sense 
venereal,  and  may  appear  in  patients  who  have  never  had  venereal 
disease  of  any  kind.  The  author  is,  however,  inclined  to  the  belief 
that  syphilis  is  often  a  predisposing  factor. 

Balano-posthitis  is  very  favorable  to  the  development  of  vegeta- 
tions, and  they  are  quite  likely  to  develop  in  any  case  where  the  pre- 
puce is  long  or  constricted. 

Lymphajs^gitis. 

Inflammation  of  the  lymphatic  vessels  of  the  penis  occasionally 
occurs  in  urethritis.  The  prepuce  becomes  swollen  and  oedematous, 
and  sometimes  presents  an  appearance  identical  with  erysipelas. 
Abscesses  may  form  along  the  lymphatic  vessels.  Occasionally  the 
inflammation  is  limited  to  a  few  lymphatic  vessels,  and  does  not  in- 
volve the  entire  prepuce. 

Lymphangitis  is  due  to  secondary  and  probably  mixed  infection 
rather  than  to  the  germs  of  the  urethral  inflammation  per  se. 

In  cachetic  subjects,  sloughing  of  the  prepuce  and  denudation  of 
the  penis  may  occur. 

Chronic  induration — indurating  oedema — is  an  occasional  result 
of  lymphangitis.    This  is  most  likely  to  occur  in  syphilized  patients. 

Treatment. 

The  treatment  of  urethritis  comprises  a  greater  variety  of  methods 
and  remedies  than  almost  any  disease  which  could  be  mentioned. 
This  fact  is  in  itself  strong  circumstantial  evidence  of  the  self-limited 
and — as  far  as  specific  medication  is  concerned — incurable  character 
of  the  disease.  Manifold  as  are  the  panaceas  and  specifics  for  ure- 
thritis, the  fact  still  remains  that  no  system  of  treatment  or  line  of 
specific  medication,  when  taken  alone,  has  materially  diminished  the 
average  duration  and  severity  of  the  disease,  excepting  those  meas- 
ures based  upon  the  principle  of  its  sell-limitation  and  an  apprecia- 
tion of  the  inadvisability  and  impracticability  of  attempts  to  jugulate 
it.  Such  measures  of  treatment  have  accomplished  much ;  panaceas, 
nothing  Vjut  injury  on  the  average.  There  is  scarcely  a  physician  in 
practice,  and  probably  not  one  "man  about  town, "but  imagines  that 
he  has  a  remedy  which  is  a  specific  for  the  "  clap,"  the  several  remedies 
varying  in  position  and  legitimacy  from  the  fallacious  injection  Brou 
to  the  more  modern  ai)j)lication  of  the  bichloride  of  mercury  by  the 
retro-injection  method.  The  author  discredits  the  statements  of  those 
surgeons  who  claim  to  cure  cases  of  virulent  urethritis  in  a  week  or 
ten  days,  or  i)erhaps  less,  quite  as  much  as  the  statements  of  the  vet- 


462  LTDSTON — DISEASES  OF  THE   MALE  URETHRA. 

eran  "  rounder"  who  has  a  little  preparation  that  "  knocks  it  in  three 
days."  It  is  not  to  be  believed  that  by  any  special  system  of  medi- 
cation a  virulent  urethritis  is  ever  cured  in  any  such  time.  The 
author  has  hunted  down  all  the  wonderful  specifics  that  have  ever 
been  called  to  his  attention,  and  has  tried  them  all  faithfully,  but  has 
not  yet  succeeded  in  finding  a  remedy  which  produces  the  wonderful 
results  claimed  by  some  surgeons  and  by  quite  a  proportion  of 
patients. 

Mr.  Milton  has  well  illustrated  the  fallaciousness  of  gonorrhoeal 
specifics  in  a  list,  taken  from  various  sources,  which  comprises  sev- 
eral hundred  infallible  remedies,  all  of  which  have  been  tried  and 
found  wanting. 

Dri-vdng  a  gonorrhoea  to  a  cure  is  bad,  as  well  as  unsuccessful, 
practice  in  general,  and  much  harm  nisbj  come  of  it ;  the  best  results 
being  apt  to  follow  a  "coaxing"  method,  i.e.,  mild  and  persistent 
treatment  and  the  acceptance  of  the  inevitable  for  several  weeks. 
There  is  but  one  substitute  for  this  line  of  treatment,  and  that 
is  one  which  will  be  shortly  mentioned,  involving  absolute  rest. 
If  a  remedy  is  ever  discovered  which  will  cure  every  case,  even 
in  from  three  to  six  weeks,  the  event  will  be  hailed  as  presaging  a 
surgical  millennium.  The  author  would  be  very  well  satisfied  if 
a  remedy  could  be  found  which  would  invariably  cure  gonorrhoea  in 
six  weeks  or  so,  meanwhile  permitting  the  patient  to  go  about  his 
business.  No  matter  what  system  of  treatment  may  be  followed,  a 
better  average  result  than  this  is  not  often  to  be  hoped  for  in  virulent 
urethritis.  If,  however,  the  surgeon  counts  his  cases  of  bastard  clap 
and  the  milder  forms  of  urethritis  in  with  his  statistics,  he  may 
achieve  in  a  large  proportion  of  instances  the  wonderful  results 
claimed  by  many,  and  this  remark  is  particularly  pertinent  when  we 
consider  the  fact  that  the  average  surgeon  must  necessarily  treat  at 
least  a  half-dozen  cases  of  mild  urethritis  or  bastard  clap  for  every 
virulent  case  that  comes  under  his  observation.  It  will  be  found 
that,  with  due  regard  to  the  self-limitation  of  the  disease  and  the  in- 
tolerance of  the  urethra  for  harsh  measures  of  treatment,  fewer  cases 
of  chronic  urethritis  will  be  seen,  and  fewer  strictures  and  other 
sequelae  will  result,  than  with  those  systems  of  treatment  which  are 
said  to  cure  within  a  few  days.  There  are,  to  be  sure,  cases  which 
will  present  themselves  to  our  observation  that  are  likely  to  shake 
our  faith  in  this  method  of  management.  How  often  we  hear  of 
some  self-satisfied  voluptuary  who  some  years  ago  had  a  gonorrhoea 
that  proved  obstinate  to  the  best  professional  skill  for  months  and 
months,  but  Avho  finally  recovered  and  now  has  a  prescription  which 
has  cured  him  of  from  half  a  dozen  to  twenty  attacks  of  urethritis ! 


TREATMENT.  463 

The  surgeon  should  not  let  such  cases  shake  his  faith  in  his  own  pro- 
fessional ability,  for  these  men  are  constantly  deluding  themselves. 
The  only  virulent  urethritis  that  the  patient  under  consideration 
ever  had  was  the  first  attack,  from  contagion,  the  subsequent  attacks 
being  bastard  clap  founded  upon  the  damage  done  by  the  old-time 
gonorrhoea.  Sooner  or  later  a  second  attack  of  violent  urethritis — or 
perhaps  a  mild  case  with  a  tendency  to  chronicity — is  experienced  by 
such  patients  and  not  only  explodes  their  faith  in  the  erstwhile 
panacea,  but  gives  no  end  of  trouble,  and  necessitates  for  its  cure 
surgical  measures  adapted  to  the  removal  of  the  cause  of  those 
numerous  attacks  which  the  alleged  specific  so  readily  subdued. 

In  spite  of  what  has  been  said  regarding  the  parasitic  or  microbic 
origin  of  virulent  urethritis,  the  author  fails  to  see  any  practical  re- 
sults in  the  way  of  improved  methods  of  treatment — not  that  this  is 
in  any  sense  an  argument  against  the  microbic  character  of  the  disease, 
but  it  certainly  signifies  its  self -limitation.  The  investigations  of 
bacteriologists  who  unhesitatingly  accept  the  gonococcus  of  Neisser 
have  shown  that  the  poison  of  the  disease  infects  the  entire  thickness 
of  the  mucous  membrane  and  the  submucous  cellular  tissue  so  com- 
pletely that  repair  cannot  take  place  in  well-pronounced  cases  until 
the  layers  of  affected  cells  have  been  replaced  by  new  and  insuscep- 
tible connective-tissue  cells  from  beneath.  This  condition  of  affairs 
proves  positively  that  nothing  short  of  caustic  applications  capable 
of  destroying  the  entire  thickness  of  the  mucous  membrane  can  by 
any  possibility  abort  a  virulent  urethritis  when  once  it  is  thoroughly 
established.  As  a  corollary,  it  is  obvious  that  attempts  at  the  abor- 
tion of  a  virulent  urethritis  should  be  made  only  in  the  very  incipiency 
of  the  disease,  before,  in  fact,  it  is  possible  to  determine  whether  or 
not  we  have  to  deal  with  a  simple  or  virulent  case  of  inflammation ; 
for  inasmuch  as  the  different  grades  of  urethritis  often  begin  in  pre- 
cisely the  same  manner,  it  is  impossible  to  tell  for  a  few  hours,  or 
perhaps  several  days,  whether  or  not  we  have  to  do  with  a  virulent 
type  of  the  affection  or  with  the  simpler  and  more  curable  variety. 
Any  form  of  treatment  the  efficacy  of  which  is  supposed  to  depend  upon 
the  action  of  antiseptics  on  the  specific  germs  of  the  disease  must,  in 
order  to  shorten  the  duration  of  the  affection,  be  applied  within  a  few 
hours  of  its  inception.  Thus  the  disease  can  be  aborted — if  the  term 
abortion  is  proper  as  applied  to  something  which  does  not  already 
exist;  the  f)''^i*^on  begins  to  produce  irritation  of  the  epithelium 
of  the  urethral  mucous  membrane  very  soon  after  its  introduction  into 
the  canal,  and  if  the  virus  be  destroyed  in  loco,  the  disease  not  hav- 
ing yet  fairly  begun,  it  may  be  said  to  have  been  prevented  rather 
than  aborted. 


464  LYDSl  ON —DISEASES   OF   THE   MALE   UKETHKA. 

The  tAvo  methods  of  treatment  applicable  to  urethritis  may  for  the 
purpose  of  discussion  be  divided  into  the  jugulative  or  abortive  and 
the  methodical  or  rational  systems. 

Aboetive  Teeatment. 

The  abortive  method  of  treatment  has  been  generally  understood 
to  imply  the  substitution  of  a  simple  for  a  specific  inflammation. 
This  practice  is  a  relic  of  bygone  days,  which  has  impelled  surgeons 
of  excellent  reputation — and  undoubted  wisdom  in  other  directions — 
to  rub  the  pure  crayon  of  nitrate  of  silver  in  eyes  affected  by  viru- 
lent conjunctivitis.  It  is  even  possible  that  there  are  surgeons  at  the 
present  time  who  advocate  this  Terj  method  of  treatment  for  this  par- 
ticular disease.  During  the  author's  term  of  service  as  hospital  in- 
terne, he  saw  pure  nitrate  of  silver  applied  on  several  occasions,  and 
in  every  instance  it  was  followed,  not  by  the  substitution  of  a  simple 
for  a  specific  inflammation,  but  by  complete  destruction  of  the  eye  as 
far  as  its  casual  capacity  was  concerned.  The  author  remembers  asking 
one  of  the  hospital  staff'  who  applied  this  method  of  treatment  in  a  case 
of  virulent  ophthalmia,  under  the  adAdce  of  a  prominent  specialist, 
how  he  knew  which  had  destroyed  the  sight,  the  disease  or  the  treat- 
ment. He  replied  that  it  was  impossible  to  say  positively,  but  that 
it  must  be  the  disease,  because  "they  all  went  that  way  anyhow." 
Arguments  are  useless  as  opposed  to  such  logic  as  this,  but  it  is 
hoped  that  it  is  unnecessary  to  protest  against  such  pernicious  doc- 
trines as  applied  to  the  treatment  of  urethritis. 

The  abortive  method  of  treatment  as  applied  to  urethritis  should 
properly  imply,  not  the  fossilized  and  sophisticated  idea  of  the  sub- 
stitution of  one  type  of  inflammation  for  another,  but  (1)  the  removal 
as  far  as  may  be  of  the  Adrulent  germs  which  have  been  deposited  upon 
the  surface  of  the  mucous  membrane,  and  which,  although  they  have 
begun  to  manifest  their  presence  by  slight  irritation  at  the  meatus  or 
just  within  it,  have  not  yet  deeply  penetrated  into  the  substance  of 
the  mucous  membrane  and  infected  the  subjacent  cells ;  and  (2)  the  neu- 
tralization of  the  germs  and  their  products  by  means  of  antiseptics 
or  germicides — which  in  this  instance  imply  all  chemical  substances 
capable  of  neutralizing  the  organic  poison  of  urethritis  without  de- 
stroying the  mucous  membrane. 

These  requirements  are  the  more  readily  fulfilled  because  the  dis- 
ease begins  at  the  meatus,  or  at  most  in  the  fossa  navicularis,  and 
gradually  affects  contiguous  areas  of  mucous  membrane.  The  sub- 
stance most  generally  used  in  the  abortive  method  of  treatment  is 
nitrate  of  silver.     This  may  be  used  in  two  ways :  (1)  By  the  injec- 


ABORTIVE  TEEATMENT.  465 

tion  of  a  mild  solution  at  frequent  intervals ;  (2)  by  means  of  a  single 
injection  of  a  comparatively  strong  solution.  If  properly  done,  and 
at  an  appropriate  period  in  the  incipiency  of  the  disease,  either  one 
of  these  methods  is  usually  safe  and  is  not  likely  to  result  in  stric- 
ture— the  principal  danger  of  the  abortive  method.  A  solution  of 
nitrate  of  silver,  fifteen  grains  to  the  ounce,  may  be  thrown  into  the 
canal  by  means  of  a  small  drop  syringe,  which  is  passed  into  the 
urethra  for  about  two  inches,  the  fluid  being  ejected  as  the  syringe  is 
slowly  withdrawn.  It  is  held  in  the  urethra  for  a  few  seconds,  and  a 
weak  solution  of  chloride  or  bicarbonate  of  sodium  is  then  thrown 
into  the  canal,  the  patient  being  instructed  to  urinate  immediately 
thereafter.  If  this  be  carefully  done  when  slight  discharge  and 
itching  at  the  meatus  are  first  observed,  the  method  is  apt  to  prove 
successful  and  is  devoid  of  danger,  although  in  general  it  is  not  a 
good  method  for  application  by  the  general  practitioner.  In  lieu  of 
the  strong  preparation,  a  solution  of  one-half  grain  of  nitrate  of  sil- 
ver to  the  ounce  of  water  may  be  given  and  used  every  two  hours  for 
twentj^-four  hours  or  less,  the  treatment  being  stopped  as  soon  as 
pronounced  smarting  during  micturition  develops. 

That  nitrate  of  silver  is  efficacious  in  destroying  the  materies 
morbi  of  virulent  inflammation  is  shown  by  the  excellent  results  ob- 
tained by  Crede  in  the  prophylaxis  of  ophthalmia  neonatorum  by  the 
instillation  into  the  eyes  of  the  new-born  infant  of  a  two  per  cent, 
solutioii  of  that  drug.  While  the  use  of  the  nitrate  of  silver  in  care- 
less hands  is  inimical  to  the  welfare  of  the  urethra,  the  author  is 
satisfied  that,  if  properly  used,  its  dangers  are  greatly  exaggerated. 
Injections  in  a  strength  of  thirty  grains  to  the  ounce  may  often  be 
used  in  chronic  urethritis,  with  the  best  possible  results.  Such  in- 
jections, however,  should  onlj^  be  given  by  the  deep  syringe. 

The  method  which  the  author  prefers  for  the  abortion  of  urethritis 
is  the  prolonged  and  systematic  irrigation  of  the  anterior  urethra 
with  a  solution  of  permanganate  of  potassium  in  a  strength  of  from 
1  in  10,000  to  1  in  5,000.  This  should  be  used  as  warm  as  can  be 
comfortably  borne  by  the  patient  and  kept  up  for  one-half  or  three- 
quarters  of  an  hour  at  a  time,  the  process  being  repeated  twice  daily 
for  three  or  four  days,  after  which  time  the  treatment  should  be  given 
once  daily  for  two  or  three  weeks.  Care  should  be  taken  not  to  use 
the  water  too  hot,  as  destruction  of  the  urethral  ei)ithelium  may  easily 
be  produced ;  this  is  a  point  too  often  forgotten.  The  patient  may 
occasionally  receive  benefit  from  this  same  treatment  if  self-adminis- 
tered by  means  of  the  ordinary  penis  syringe,  although  irrigation 
through  the  short  nozzle  at  the  hands  of  the  surgeon  is  best.  Long 
nozzles  for  irrigation  should  not  be  used.  The  author  has  found  a 
Vol.  I.— 30 


466  LYDSTON — DISEASES  OF  THE   MALE  URETHRA. 

sliort  nozzle  of  his  own  device  to  be  the  most  satisfactory  of  all  the 
irrigating  appliances  that  he  has  used.  The  irrigation  should  be 
made  by  means  of  the  ordinary  fountain  syringe,  care  being  taken 
not  to  have  the  elevation  of  the  douche  bag  too  great,  as  injurious 
pressure  upon  the  urethral  walls  may  be  thereby  produced.  During 
the  continuation  of  this  treatment,  the  patient  should  be  placed  upon 
the  usual  internal  treatment  with  alkalies,  and  the  usual  restrictions 
regarding  diet  and  exercise  should  be  imposed.  It  is  sometimes 
advantageous  to  combine  the  internal  administration  of  oil  of  sandal- 
wood with  the  irrigation  method.  The  author  would  especially  en- 
join caution  in  the  matter  of  too  speedy  cessation  of  treatment.  As 
a  rule  no  discharge  will  be  noticeable  after  the  first  twelve  or  twenty- 
four  hours,  hence  it  is  very  often  difficult  to  convince  patients  of  the 
necessity  of  several  weeks'  careful  treatment.  Experience  shows, 
however,  that  unless  prolonged  treatment  be  instituted,  the  develop- 
ment of  the  disease  will  be  simply  retarded,  not  aborted. 

Eational  or  Methodical  Treatment. 
General  Management. 

The  rational  method  of  treatment  is  of  necessity  the  one  which  we 
are  most  often  called  upon  to  prescribe,  for  the  reason  that,  as  a 
rule,  the  patient  rarely  seeks  advice  until  urethritis  is  well  established. 

The  term  "rational"  is  used  in  cpntradistinction  to  the  expect- 
ant method  of  Fournier,  Diday,  and  others,  which  consists  chiefly  in 
the  administration  of  placebos. 

In  cases  of  simj)le  urethritis,  mild  measures  of  treatment  may  be 
directly  curative,  which  cannot  be  said  of  the  more  active  types  of 
the  disease.  Attention  to  genito-urinary  hygiene,  regulation  of  the 
diet,  the  administration  of  mild  laxatives,  and  the  use  of  weak  astrin- 
gent injections  usually  suffice  for  the  cure  of  the  milder  cases  within 
a  few  days ;  at  least,  such  measures  check  the  discharge.  From  what 
has  been  said  of  the  causes  of  the  simple  forms  of  inflammation  of 
the  urethra,  it  is  obvious  that  in  the  majority  of  instances  surgical 
treatment  is  necessary  for  a  complete  cure,  either  in  conjunction  with 
medical  treatment  or  following  the  cessation  of  the  urethral  discharge. 
Thus  dilatation  or  cutting  operations  are  required  for  stricture ;  the 
contracted  meatus  must  be  cut  and  congested  and  granular  patches 
must  be  stimulated  to  repair  by  means  of  applications  through  the 
endoscope,  or  other  measures  applicable  to  the  treatment  of  certain 
forms  of  chronic  gleet  must  be  instituted. 

So  intimately  connected  are  simple  urethritis  and  chronic  patho- 
logical conditions  of  the  canal  that  it  is  unnecessary  to  discuss  further 


RATIONAL  TREATMENT.  467 

the  treatment  of  what  must  obviously  be  in  the  majority  of  instances 
merely  a  symptom.  The  author  sometimes  wonders  whether  it  would 
not  be  safe  to  distinguish  broadly  simple  from  virulent  urethritis  by 
saying  that  the  simple  form  comprises  the  effects  of  venereal  excite- 
ment, intemperance,  and  contact  of  irritating  secretions  or  a  special 
poison  with  a  canal  at  one  time  affected  with  severe  inflammation, 
while  virulent  inflammation  is  the  result  of  inoculation  of  a  highly 
elaborated  poison  upon  the  virgin  urethra,  with  or  without  the  co- 
operation of  the  other  factors  just  mentioned.  The  author  is  tempted 
to  believe  that  an  individual  who  has  once  had  a  virulent  attack  of 
urethritis  becomes  so  insusceptible  to  the  disease  that  infection,  when 
taken  alone,  never  thereafter  causes  a  virulent  type  of  inflammation, 
apparently  virulent  (secondary)  attacks  being  due  to  the  super-addi- 
tion of  some  extraneous  source  of  irritation.  This  may  seem  far- 
fetched, but  let  it  be  remembered  that  the  subsequent  history  of  the 
gonorrhoeal  patient  is  usually  a  succession  of  comparatively  mild 
attacks.  Is  this  because  he  is  more  choice  in  his  selection  of  females? 
But,  it  may  be  urged,  "  the  mild  attacks  are  due  to  pre-existing  dam- 
age in  the  canal,"  i.e.,  remnants  of  the  old  attack.  Very  true,  but 
wherein  do  such  lesions  protect  the  patient  from  virulent  attacks,  if 
exposure  be  granted— as  it  must  be  in  most  cases? 

The  most  important  principle  in  the  management  of  severe  urethri- 
tis is  the  maintenance  of  physical  and  sexual  rest.  It  would  be  fair 
to  qualify  the  statement  that  there  is  no  specific  for  urethritis  by 
saying  "with  the  exception  of  absolute  rest,"  so  great  is  the  benefit  to 
be  derived  from  it.  It  is  an  unfortunate  circumstance  that  individuals 
with  gonorrhoea  labor  under  the  fatuitous  idea  that  the  disease  is  in 
itself  not  a  serious  one — as  they  usually  express  it,  "  no  worse  than 
a  cold,"— and  it  is  consequently  difficult,  indeed  it  is  impossible,  in 
the  majority  of  cases,  to  induce  them  to  take  a  complete  rest.  They 
wish  to  be  cured  promptly,  but  upon  entirely  different  principles 
from  those  which  govern  the  management  of  other  acute  inflammatory 
affections.  A  man  with  a  sharp  attack  of  urethritis  is  certainly  very 
sick,  yet  how  seldom  can  he  be  induced  to  take  to  his  bed  and  be 
treated  upon  the  same  rational  principles  that  are  carried  out  in  other 
inflammations !  A  man  with  a  fractured  limb  is  of  necessity  com- 
pelled to  rest,  and  independently  of  the  mechanical  obstacle  to  move- 
ment, it  is  not  difiicult  to  convince  him  that  absolute  quiet  is  neces- 
sary for  a  cure.  There  is  little  or  no  danger  in  a  simple  fracture, 
yet  the  patient  is  perfectly  tractable.  There  is  great  danger,  usually, 
in  cases  of  virulent  urethritis,  yet  it  is  seldom  possible  to  convince 
the  patient  that  quiet  is  necessary.  A  moment's  reflection  will  con- 
vince the  reader  of  the  truth  of  the  assertion  that  there  are  few  dis- 


468  LYDSTON — DISEASES   OF  THE  MALE  URETHRA.      . 

eases  indeed  that  are  characterized  by  so  many  and  sucli  severe 
remote  pathological  possibilities  as  is  that  under  consideration. 
Many  a  man,  crippled  at  middle  age,  and  whose  life  is  ever  after 
afflicted  with  numerous  physical  annoyances  or  perhaps  serious 
bodily  infirmities,  is  indebted  therefor  to  a  severe  attack  of  gonorrhoea 
experienced  in  his  youth.  The  immediate  results  of  a  gonorrhoea  are 
often  bad  enough.  There  is  nothing  more  painful  than  an  attack  of 
epididymitis,  a  disease  which  may  produce  sterility,  and  in  certain 
constitutions  may  lead  to  abscess  or  gangrene  and  total  loss  of  the 
organ  involved.  This  complication  is  among  the  most  frequent  re- 
sults of  urethritis.  Inflammation  of  the  bladder,  of  an  acute  and 
dangerous  form,  is  occasional,  and  is  productive  of  much  suffering. 
Should  the  bladder  become  involved  in  any  degree,  it  is  indeed  a  for- 
tunate indi\'idual  who  is  not  ever  thereafter  annoyed  with  vesical  irri- 
tability, or  perhaps  chronic  inflammation.  Prostatitis  also  leaves 
disagreeable  and  usually  permanent  effects. 

Stricture,  the  most  important  of  the  sequelae  of  gonorrhoea,  is  pro- 
ductive in  some  instances  of  the  most  profound  pathological  disturb- 
ances in  the  proximal  portion  of  the  genito-urinary  tract. ,  Inflamma- 
tion of  the  bladder,  calculous  disease,  inflammation  and  dilatation  of 
the  ureters,  surgical  diseases  of  the  kidney,  and  even  Bright 's  disease 
of  the  ordinary  form,  are  often  directly  traceable  to  it.  There  are 
very  few  indi\dduals  who  have  suffered  from  pronounced  stricture, 
who  are  not  affected  either  with  renal  disease  or  with  what  is  prac- 
tically the  same  thing,  a  locus  minoris  resistentice  in  the  direction  of 
the  kidneys,  which  favors  the  development  of  acute  or  chronic  Bright's 
disease  from  apparently  trivial  causes.  There  are  few  cases  of  gon- 
orrhoea, indeed,  but  affect  to  a  greater  or  less  extent  the  prostate  body, 
and  it  is  the  author's  view  that  many  individuals  who  in  after-life  are 
afflicted  with  prostatic  hypertrophy  owe  that  condition  to  the  effects 
of  an  early  gonorrhoea. 

It  needs  but  a  casual  survey  of  the  morbid  possibilities  of  urethri- 
tis to  convince  one  that  it  is  a  serious  affection.  It  is  an  undeniable 
fact  that  gonorrhoea  is  the  most  dangerous  of  the  venereal  diseases, 
for  through  the  medium  of  its  sequelae  and  complications  the  disease 
is  the  cause  of  more  deaths  than  can  be  justly  attributed  to  the  direct 
or  indirect  influence  of  syphilis.  By  comparison,  chancroid  is  essen- 
tially a  benign  disease.  Subtract  the  evil  effects  of  gonorrhoea  from 
the  list  of  human  ills,  and  the  resulting  increase  in  the  longevity  and 
happiness  of  the  race  would  be  something  marvellous. 

It  is  the  author's  belief  that  every  patient  with  a  virulent  urethritis 
should  be  confined  to  his  bed  for  from  one  to  two  weeks,  and  that, 
if  this  could  be  accomplished,  the  majority  of  cases  would  not  only 


RATIONAL  TREATMENT.  469 

be  subdued  within  two  or  three  weeks,  but  stricture  and  other  com- 
plications and  sequelae  would  be  almost  unheard  of,  providing  the 
medical  and  surgical  treatment  adopted  in  conjunction  with  rest  were 
not  in  itself  productive  of  injury.  In  the  comparatively  few  instances 
in  which  the  author  has  been  able  to  carry  out  this  plan,  the  results 
have  invariably  substantiated  this  opinion.  Sexual  rest  is  a  positive 
necessity,  and  it  is  hardly  necessary  to  state  that  this  implies  both 
mental  and  physical  sexual  repose.  The  mind  must  be  kept  free  from 
sexual  impressions  and  ideas  of  all  kinds. 

Second  only  in  importance  to  rest  is  attention  to  diet.  A  restricted 
regimen  is  necessary,  not  only  because  of  its  beneficial  effects  from 
an  antiphlogistic  standpoint,  but  for  the  purpose  of  limiting  the  waste 
products  excreted  with  the  urine.  It  is  upon  the  amount  and  charac- 
ter of  these  waste  products  that  the  irritating  properties  of  the 
urine  depend,  and  there  is  nothing  so  efficacious  in  diminishing  its 
acridity  as  attention  to  diet,  the  ideal  regimen  being  bread  and  milk. 
Stimulants,  such  as  alcoholics  of  all  kinds,  tea  and  coffee,  should  be 
interdicted.  The  more  closely  a  vegetable  diet  is  adhered  to  the 
better,  providing  a  bread-and-milk  regimen  be  not  acceptable. 
Asparagus  and  tomatoes,  however,  are  to  be  avoided. 

It  is  not  considered  necessary  by  the  majority  of  surgeons  to  re- 
strict the  patient  in  the  manner  of  indulgence  in  tobacco.  Chewing  is 
probably  not  at  all  injurious,  but  this  is  not  true  as  regards  smoking. 
Practical  observation  shows  that  smoking,  unless  in  extreme  modera- 
tion, is  decidedly  inimical  to  the  cure  of  inflammatory  troubles  of  the 
genito-urinary  tract.  It  is  well,  therefore,  to  prohibit  it  as  a  matter 
of  routine.  Some  of  the  author's  patients  have  acknowledged  that 
they  have  themselves  noticed  a  difference  in  their  condition  according 
to  the  extent  of  their  indulgence  in  tobacco.  The  late  Dr.  Bumstead 
held  the  opinion  that  both  smoking  and  chewing  produced  relaxation 
of  the  genital  organs  and  tended  to  perpetuate  urethral  discharges. 
Tobacco  in  excess  certainly  makes  the  nervous  system  irritable  and 
tends  to  promote  sexual  excitability.  The  evil  influence  of  smok- 
ing upon  the  mucous  membranes  is  probably  not  limited  to  those  of 
the  nose  and  throat,  but  also  extends  to  all  the  mucous  tracts  of  the 
body  through  the  constitutional  effects  of  the  weed. 

The  alkaline  mineral  waters  should  be  given  for  the  purpose  of 
diluting  and  increasing  the  bulk  of  the  urine.  To  these  mineral 
waters  may  be  added  the  citrate,  acetate,  or  bicarbonate  of  potas- 
sium with  the  object  of  still  further  lessening  the  irritating  prop- 
erties of  the  urine  by  neutralizing  its  acidity.  Profuse  diuresis, 
I)roviding  the  urine  is  bland  and  non-irritating,  is  highly  desirable, 
for  the   urethra  is  like  an  infected  wound  in  a  certain  sense,  and 


470  LYDSTON — DISEASES  OF  THE  MALE  URETHRA. 

requires  frequent  irrigation  for  tlie  purpose  of  cleansing  the  infected 
surfaces. 

Cleanliness  is  absolutely  essential,  and  individuals  with  a  long 
prepuce  should  be  particularly  cautioned  to  cleanse  the  parts  beneath 
it  thoroughly,  and,  if  possible,  to  retract  it  and  bathe  the  glans  several 
times  daily,  to  prevent  balanitis  and  further  cultivation  of  the  pro- 
ducts of  virulent  inflammation. 

Some  attention  is  necessary  to  the  dressing  of  the  penis.  One 
of  the  most  pernicious  practices  that  can  be  adopted  is  to  bind  ab- 
sorbent cotton  or  other  material  over  the  meatus,  a  plan  which  is  fre- 
quently followed  by  patients  with  a  long  prepuce,  in  the  orifice  of 
which  absorbent  cotton  or  lint  may  be  packed  with  great  facility. 
Common  sense  should  teach  the  surgeon  that,  inasmuch  as  the  in- 
flammation of  the  urethra  is  due  to  the  inoculation  of  successive  areas 
of  the  mucous  membrane  with  the  virulent  products  of  inflammation, 
the  process  extending  gradually  from  the  anterior  to  the  deeper  por- 
tions of  the  urethra,  any  dressing  which  dams  back  the  discharge 
must  necessarily^  feed  the  pathological  process  and  enhance  the  dan- 
ger of  its  extension  into  the  deeper  portions  of  the  canal.  Improper 
dressing  is  frequentlj^  the  cause  of  serious  comj)lications.  A  very 
simple  plan  is  for  the  patient  to  roll  the  shirt  up  in  front  out  of 
harm's  way  and  to  pin  upon  the  tail  of  that  garment  a  soft  white  hand- 
kerchief or  napkin,  which  is  drawn  through  beneath  the  perineum 
and  up  over  the  penis  in  such  a  manner  that  one  corner  of  the  nap- 
kin may  be  tucked  down  each  leg  of  ihe  pantaloons,  with  numerous 
folds  of  the  soft  cloth  resting  in  the  crotch  of  that  garment  in  such  a 
way  that  the  penis  rests  therein,  the  meatus  at  the  same  time  being 
unobstructed.  Another  very  excellent  plan  is  to  pin  the  toe  of  a 
stocking  upon  the  drawers  or  pantaloons  in  such  a  manner  that  the 
penis  may  hang  therein  without  the  meatus  coming  in  contact  with 
the  improvised  bag.  In  the  bottom  of  this  receptacle  a  little  absorb- 
ent cotton  may  be  placed  and  frequently  changed.  There  are  several 
cloth  gonorrhoea  bags  upon  the  market  which  ansAver  the  same  pur- 
pose. The  penis  should  never  be  dressed  and  allowed  to  remain  in 
the  upright  position.  By  attention  to  these  little  details  cleanli- 
ness may  be  secured,  and  at  the  same  time  free  drainage  of  the 
affected  membrane  facilitated.  Rubber  protectives  should  never  be 
used. 

Inasmuch  as  it  is  impossible  for  us  to  abort  the  inflammation 
when  it  has  already  frankly  begun,  it  is  obvious  that  we  must  content 
ourselves  with  a  not  too  officious  management  of  the  case  until  the 
normal  process  of  repair  begins. 

One  of  the  best  measures  for  facilitating  resolution  of  inflammation 


EATIONAL  TREATMENT.  471 

is  the  application  of  heat,  and  it  is  nowhere  more  efficacious,  if  prop- 
erly applied,  than  in  inflammations  about  the  sexual  apparatus.  It 
will  be  found  that  heat  applied  by  means  of  the  sitz-bath  of  from 
one-half  to  one  hour's  duration  several  times  daily  will  materially 
assist  in  the  successful  management  of  the  urethritis,  particularly 
if  there  exists  any  irritation  about  the  prostate  or  neck  of  the 
bladder.  When  the  patient  will  consent  to  keep  perfectly  quiet,  it 
is  the  most  valuable  auxiliary  method  of  treatment  at  our  command. 
The  value  of  the  hot  sitz-bath  has  been  questioned,  but  the  author  is 
convinced  of  its  efficacy. 

In  lieu  of  the  more  general  application  of  heat  by  means  of  the 
bath,  prolonged  soaking  of  the  penis  in  hot  water  will  be  found  to  be 
beneficial.  When  urination  is  very  painful,  relief  may  be  obtained 
by  passing  the  urine  while  the  organ  is  immersed  in  a  vessel  of  hot 
water. 

The  use  of  remedies,  both  internal  and  local,  should  be  guided, 
not  only  by  a  knowledge  of  the  natural  course  of  the  disease,  but  by 
the  conditions  present  at  various  stages  of  the  affection  in  each  in- 
dividual patient.  It  would  be  absurd,  as  well  as  pernicious,  to  treat 
a  case  complicated  in  the  stationary  stage  by  inflammation  of  the 
bladder  or  prostate  in  the  routine  fashion  prescribed  for  the  aver- 
age uncomplicated  case  at  the  same  period  of  the  disease. 

Internal  Medication. 

The  range  of  application  of  internal  medicaments  in  acute  ure- 
thritis is  not  very  extensive,  the  so-called  specific  remedies  being  espe- 
cially limited  in  number.  During  the  increasing  stage  of  the  disease 
there  is  apt  to  be  considerable  fever,  and  the  tincture  of  aconite  or 
veratrum  viride  will  be  found  to  be  useful.  The  author  believes  that 
these  remedies  are  not  used  sufficiently  often. 

Alkaline  diluents  should  always  be  given  throughout  the  course  of 
the  disease,  either  alone  or  in  combination  with  other  drugs.  The 
fluid  extract  of  pichi  {Fahiana  imbricata) ,  a  drug  recently  put  upon 
the  market,  appears  to  have  an  excellent  effect  in  lessening  the  irri- 
tating properties  of  the  urine  and  soothing  the  inflamed  mucous  mem- 
brane. Combinations  of  buchu,  slippery  elm,  uva  ursi,  linseed,  etc., 
are  all  beneficial,  especially  if  given  in  infusions,  their  action  in  this 
disease  being  essentially  the  same  as  in  inflammation  of  the  bladder. 
The  ergot  of  rye  and  the  ergot  of  corn  {Ustilago  maidis)  have  been 
recommended  as  exerting  a  si)ecific  effect  upon  the  disease.  In  the 
early  stages  of  the  affection  ergot  does  not  seem  to  be  of  any  particu- 
lar service,  and,  moreover,  is  very  disagreeable  to  take.     In  the  later 


472  LYDSTON — DISEASES   OE  THE   MALE  URETHRA. 

stages  of  tlie  affection,  however,  it  undoubtedly  exerts  an  astringent 
influence  upon  the  inflamed  surface,  and  may  be  given  in  quite  lib- 
eral doses,  with  marked  benefit  in  some  cases. 

The  fluid  extract  of  corn  silk  {Stigmata  inaidis) ,  in  doses  of  one 
drachm  everj^  two  or  three  hours,  has  been  highly  recommended  in 
the  treatment  of  the  acute  stage  of  gonorrhoea.  The  author  has 
failed  to  notice  any  special  benefit  derived  from  this  remedy  in  acute 
gonorrhoea.  It  has,  however,  seemed  to  be  beneficial  in  some  cases 
of  catarrhal  gleet. 

It  is  desirable  to  administer  some  anaphrodisiac  preparation  dur- 
ing the  height  of  the  disease  for  the  purpose  of  allaying  sexual  ex- 
citement and  producing  a  direct  sedative  influence  upon  the  inflamed 
part.  A  dose  of  twenty  to  thirty  grains  of  bromide  of  potassium  at 
bedtime  has  usually  the  desired  effect.  If  a  more  powerful  effect  is 
desired,  the  following  mixture  will  be  found  serviceable : 

I^     Fl.  ext.  ergotge tti,xv. 

Tr.  gelsemii lUv. 

Potassii  bromidi gr.  xx. 

Tr.  byoscyami i^xxx. 

Syr.  aurantii q.  s.  ad  §  ss. 

M.    Sig.   At  bedtime. 

The  following  is  also  serviceable : 

IJ      Chloralis  hyd gr.  v. 

Tr.  aconiti  rad fliij. 

Sodii  bromidi gr.  xv. 

Aq.  camphorse q.  s.  ad.   §  ss. 

M.    Sig.  At  bedtime. 

Either  of  these  combinations  will  usually  allay  sexual  excitability 
and  prevent  or  relieve  severe  chordee.  It  may  be  necessary ,.  how- 
ever, in  some  cases  in  which  erections  are  painful  and  troublesome, 
to  administer  an  opiate.  Opium  has  a  certain  degree  of  stimulating 
effect  upon  the  sexual  organs,  which  rather  detracts  from  its  efiicacy 
as  an  anodyne  in  these  cases.  This  objectionable  feature  may  be 
avoided  by  combining  the  deodorized  tincture  of  opium  in  moderate 
doses  with  either  chloral  or  the  bromide  of  potassium.  Where  these 
various  remedies  prove  unsuccessful,  the  cold-water  coil  will  invari- 
ably afford  relief  and  has  in  addition  a  decidedly  beneficial  effect 
upon  the  inflammation.  If  the  patient  sleeps  upon  a  hard  bed,  with 
a  knotted  towel  applied  about  his  waist  in  such  a  manner  that  he 
cannot  comfortably  lie  upon  his  back,  painful  erections  are  not  so 
apt  to  occur. 


BATIONAL  TEEATMENt.  473 

Morphine  is  sometimes  necessary,  and  is  best  given  by  supposi- 
tory, plain  or  in  tbe  following  useful  combination : 

IJ      Morph.  sulph gr.  t2- 

Ext.  hyoscyami gr-i- 

Camphorse  monobromidi gr.  v. 

M.  Ft.  suppDS.  No.  1.     Sig.  At  bedtime. 

The  remedies  most  relied  upon  in  the  treatment  of  gonorrhoea  are 
the  various  balsamic  preparations.  These  should  not  usually  be 
given  during  the  increasing  stage  of  the  disease,  and  it  would  seem 
that  more  marked  benefit  is  to  be  derived  from  them  when  they  are 
not  used  early  in  the  case.  There  is,  perhaps,  no  objection  to  the 
administration  of  the  oil  of  sandalwood  in  the  increasing  stage; 
cubebs  and  copaiva,  however,  are  more  stimulating,  and  consequently 
inadvisable  at  this  time.  Sandalwood  oil  is  best  administered  in  the 
form  of  capsules  containing  from  ten  to  fifteen  minims.  Of  these, 
from  four  to  ten  may  be  given  daily.  In  lieu  of  the  capsules  the 
pure  oil  may  be  given  in  doses  of  ten  to  fifteen  drops  upon  a  lump 
of  sugar,  this  dose  being  repeated  four  or  five  times  daily.  The 
limit  of  tolerance  is  usually  indicated  by  stomachic  disturbance,  or 
quite  frequently  by  pain  in  the  back  resembling  lumbago,  this  being 
probably  nephralgia  dependent  upon  over-stimulation  and  consequent 
irritation  of  the  kidneys.  Sandalwood  is  much  more  likely  to  pro- 
duce this  result  than  are  copaiva  and  cubebs.  During  the  stationary 
and  declining  stages  copaiva  and  cubebs  may  be  given  alone  or  in 
combination.  Of  these  two  drugs,  cubebs  is  the  most  stimulating  to 
the  mucous  membrane  of  the  urethra,  but  least  irritating  to  the 
stomach.  Copaiva  occasionally  exerts  an  unpleasant  effect  in  the 
form  of  an  efflorescence  or  rash  upon  the  surface  of  the  skin,  which  is 
sometimes  so  pronounced  as  closely  to  simulate  measles.  The  cause 
of  this  untoward  action  of  copaiva  is  not  known.  It  would  appear, 
however,  that  the  eruption  is  produced  through  the  medium  of  idio- 
syncrasy, by  an  impression  made  by  the  drug  upon  the  sympathetic 
nervous  system,  analogous  to  that  produced  in  some  individuals  by 
the  ingestion  of  shell  fish,  over-ripe  tomatoes,  etc.  Quinine  and 
several  other  drugs  have  been  observed  to  produce  a  similar  reaction  • 
of  the  skin,  probably  in  the  same  way.  It  is  possible  that  defective 
renal  elimination  and  vicarious  skin  action  has  something  to  do  with 
these  cases. 

Cubebs  and  copaiva  may  be  given  in  doses  of  ten  to  twenty  drops 
of  the  oil,  four  or  five  times  daily,  either  in  capsules  or  in  the  form 
of  an  emulsion.  The  author  prefers  the  emulsion  where  the  patient 
does  not  object  to  it.  The  doses  of  the  balsams  may  be  increased  to 
the  limit  of  tolerance,  but  it  is  wise  not  to  give  them  too  liberally 


474  LYDSTON — DISEASES  OF  THE  MALE  URETHRA. 

until  the  disease  begins  to  decline.     There  are  no  better  combina- 
tions in  the  way  of  balsamic  emulsions  than  the  following : 

i^    Liq.  potassii 3  iv. 

Bals.  copaibas §  i. 

01.  gaultherise tti^x. 

Ext.  glycyrrhizae  fl §  ss. 

Muc.  acaciae q.  s.  ad  §  iv. 

Sig.  A  teaspoonful  every  two  or  three  hours. 

I^    01.  cinnamomi vix. 

01.  cubebse, 

Sp.  aether,  nit aa   §  ss. 

Muc.  acaciae  q.  s.  ad  §  viij. 

M.     Sig.  A  tablepoonful  three  or  four  times  daily. 

Cubebs  may  be  given  in  j^owder  in  doses  of  one  drachm,  two  or 
three  times  daily,  and  this  method  of  administration  sometimes 
agrees  with  the  stomach  very  much  better  than  either  the  emulsion 
or  capsule.  The  formulae  given  are  more  or  less  illustrative,  and  may 
be  varied  according  to  the  judgment  of  the  practitioner.  Yidal  ad- 
vocates the  use  of  gurjun  balsam  in  doses  of  two  grammes  before  each 
meal.  Dr.  E.  W.  Taylor  speaks  favorably  of  the  tincture  of  cannabis 
sativa  in  doses  of  ten  to  fifteen  drops  in  water  three  or  four  times 
daily. 

In  the  later  stages  of  gonorrhoea,  in  which  there  is  a  tendency  to 
chronicity,  turpentine  is  occasionally  of  value,  the  white  or  Canada 
turpentine  being  the  best  variety.  The  author  has  obtained  benefit 
in  some  cases  from  the  administration  of  the  following : 

I^    Terebinth,  alb 3  i. 

Res.  podoph gr.  ss. 

Camphorae  monobromidi 3  1. 

M.  ft.  pil.  no.  30.     Sig.   One  pill  four  times  a  day. 

In  some  instances  in  which  the  patient  is  debilitated,  the  addition 
of  iron  to  the  balsamic  preparations  is  advisable  for  its  tonic  and 
astringent  effect.  Matico  and  other  vegetable  preparations  contain- 
ing tannin  are  recommended  for  internal  administration,  but  the 
author  has  failed  to  note  any  benefit  from  these  drugs,  with  tlie  pos- 
sible exception  of  Hydrastis  canadensis,  which  has  seemed  to  be  of 
service  in  some  cases  of  chronic  urethritis. 

The  beneficial  effect  of  the  balsams  when  administered  internally 
is  rather  peculiar,  inasmuch  as  when  locally  applied  by  means  of  in- 
jections they  have  apparently  no  action  whatever.  It  would  appear 
that  in  their  passage  through  the  digestive  tract  and  circulation  they 
undergo  some  chemical  change,  by  virtue  of  which  they  exert  a  spe- 


RATIONAL  TREATMENT.  475 

cial  soothing  effect  upon  the  inflamed  mucous  membrane.  That  they 
exert  any  specific  (microbicidal)  influence  over  the  poison  of  virulent 
urethritis  is  highly  imjprobable.  Their  effect  is  certainly  not  consti- 
tutional, as  they  are  of  absolutely  no  service  in  gonorrhoea  in  the 
female,  unless  the  urethra  is  involved. 

The  local  use  of  copaiva  in  its  natural  state  does  not  seem  to  be 
beneficial.  As  a  matter  of  curiosity,  however,  it  may  be  mentioned 
that  it  has  been  recommended  for  local  use  in  vaginitis.  M.  Baratier 
(These  de  Paris)  recommends  the  use  of  copaiva  in  the  form  of  vag- 
inal suppositories  for  gonorrhoea  in  the  female,  these  suppositories 
containing  also  the  extract  of  opium.  Inasmuch  as  this  is  said  to 
cure  "in  about  twenty  days,"  it  is  hardly  necessary  to  comment  upon 
it  as  a  means  of  specific  medication,  for  certainly  a  remedy  which 
would  not  bring  about  a  cure  in  less  time  than  this  can  hardly  be 
said  to  be  very  efficacious  as  a  specific. 

The  test  has  been  made  by  M.  Ricord  and  others  of  injecting  the 
urine  of  patients  who  were  taking  large  quantities  of  copaiva  into  the 
vaginae  of  M^omen  and  urethrse  of  men  affected  with  virulent  inflam- 
mation, the  effect  being  decidedly  beneficial.  Raquin,  of  Paris,  has 
prepared  a  solution  termed  by  him  copaibate  of  soda,  which  is  said 
to  be  useful  as  an  injection  as  well  as  internally. 

Aperient  medicines  are  beneficial  throughout  the  course  of  ure- 
thritis, particularly  during  the  acute  stage.  The  saline  laxatives  are 
especially  beneficial ;  the  various  natural  mineral  waters,  notably  the 
Friedrichshall  and  Hunyadi  Janos,  being  the  best  of  these.  The 
Carlsbad  salts  are  also  of  service.  It  should  be  remarked  in  this  con- 
nection that  constipation  is  invariably  attended  with  more  or  less  con- 
gestion of  the  prostate,  and  possibly  of  the  urethra,  and  its  correction 
is  therefore  desirable.  Bruising  of  the  prostate  during  a  difficult 
stool  may  constitute  the  point*  of  departure  for  prostatic  complica- 
tions in  the  course  of  acute  urethritis. 

Naphthol  is  a  remedy  recently  recommended  in  urethritis.  This 
agent  is  claimed  to  act  by  becoming  decomposed  and  thereby  con- 
verted into  some  modification  of  phenol  (or  carbolic  acid),  which, 
coming  in  contact  with  the  mucous  membrane  of  the  genito-urinary 
tract,  is  supposed  to  destroy  the  germs  of  the  disease.  It  has  been 
given  in  doses  of  from  two  or  three  to  fifteen  grains,  several  times 
daily.  It  would  appear  to  be  indicated  in  chronic  vesical  inflamma- 
tions rather  than  in  urethral  troubles,  inasmuch  as  it  probably  makes 
the  urine  less  putrescible.  It  is  apt  to  disturb  the  stomach,  and,  as 
the  process  in  gonorrhoea  is  an  active  mixed  infection  rather  than  a 
septic  process,  the  writer  cannot  appreciate  its  advantages  over  some 
other  drugs. 


476  LYDSTON — DISEASES   OF  THE  MALE  URETHEA. 

Local  Medication. 

Local  medication  in  acute  urethritis  is  best  accomplished  by- 
means  of  injections. 

A  great  deal  of  discussion  has  been  evoked  regarding  the  advisa- 
bility of  the  injection  method  of  treatment  in  gonorrhoea.  There  is 
a  deep-grounded,  and  in  many  instances,  it  must  be  confessed,  justi- 
fiable, prejudice  against  their  use  entertained  by  the  laity,  and  inci- 
dentally by  some  surgeons.  It  is  supposed  by  many  that  the  injec- 
tion method  is  usually  responsible  for  stricture  and  other  untoward 
complications  and  sequelEB  of  urethritis.  While  this  prejudice  is 
undoubtedly  founded  in  some  instances  upon  a  substantial  basis,  the 
author  ventures  to  assert  that  it  is  the  abuse  and  not  the  use  of  in- 
jections that  is  responsible  for  their  unpleasant  results.  Injections 
of  simple  water,  if  improperly  used,  may  produce  injury,  and  it  is 
certainly  true  that  unreasonably  strong  astringent  or  antiseptic  drugs 
will,  as  a  rule,  produce  unpleasant  results.  Any  injection  of  a 
strength  sufficient  to  produce  severe  pain  is  probably  strong 
enough  to  destroy  the  already  partially  devitalized  epithelium  upon 
the  surface  of  the  mucous  membrane,  and  as  a  consequence  there 
must  necessarily  occur  at  various  points  localization  and  intensifica- 
tion of  the  inflammatory  process.  Given  at  the  proper  time  and  in  a 
proper  manner  and  strength,  injections  are  not  only  harmless  but  very 
beneficial  and  really  prophylactic  of  stricture  and  other  complica- 
tions, by  limiting  the  severity  and  duration  of  the  inflammatory  pro- 
cess. Any  form  of  injections  which  is  given  for  the  purpose  of 
cutting  short  the  disease  during  the  height  of  the  inflammation  is  apt 
to  produce  injurious  results.  It  is  an  unfortunate  fact  that  many 
surgeons  have  joined  in  the  popular  prejudice  against  injections,  for, 
as  a  consequence,  nearly  every  patient  who  has  stricture  resulting 
from  a  gonorrhoea  which  has  been  treated  by  the  injection  method, 
no  matter  how  skilfully  and  beneficially,  attributes  the  permanent 
injury  of  the  canal  to  the  treatment  of  his  urethritis ;  should  he  con- 
sult a  siirgeon  of  anti-injection  proclivities,  he  is  certain  to  have  his 
erroneous  ideas  confirmed,  much  to  the  detriment  of  the  reputation 
of  his  former  surgeon,  who  perhaps  treated  his  urethritis  upon 
strictly  scientific  and  conservative  principles. 

One  of  the  most  important  points  in  connection  with  the  injection 
method  of  treatment  is  the  selection  of  an  appropriate  syringe.  The 
ordinary  glass  syringe,  or  the  hard  rubber  syringe  with  a  long  nozzle, 
is  perhaps  responsible  for  more  prolonged  cases  of  urethritis  than 
any  that  could  be  mentioned.  The  introduction  of  such  instruments, 
even  when  performed  very  carefully,  invariably  excites  more  or  less 


RATIONAL  TREATMENT.  477 

mechanical  irritation,  and  it  is  not  unusual  to  detect  in  long-standing 
cases  a  congested  and  granular  patch  of  mucous  membrane  precisely 
at  the  spot  upon  which  the  nozzle  of  the  syringe  imjjinges  during 
injection.  Very  few  surgeons  devote  much  attention  to  the  instruc- 
tion of  the  patient  in  the  proper  use  of  the  syringe,  or  to  the 
selection  of  an  appropriate  form  of  this  instrument.  The  author  has 
seen  not  a  few  cases  of  chronic  urethritis  which  subsided  imme- 
diately upon  the  cessation  of  the  use  of  faulty  syringes.  In  some 
cases  a  cure  will  result  from  the  use,  with  a  proper  syringe,  of  the 
same  astringent  solutions  which  have  failed  to  produce  any  effect 
whatever  when  injected  through  one  of  the  long-nozzled  abominations. 
The  best  form  of  syringe  is  that  with  a  conical  point,  known  as 
the  "  Excelsior-P, "  manufactured  by  the  Goodyear  Eubber  Company. 
The  instrument  must  be  of  moderate  capacity  in  order  to  accomplish 
any  benefit ;  if  it  does  not  contain  sufficient  fluid  to  thoroughly  dis- 
tend the  urethra  when  thrown  into  the  canal  with  a  moderate  degree  of 
force,  the  medicament  is  never  brought  in  contact  with  the  entire  dis- 
eased surface.  In  using  the  syringe,  the  patient  should  be  instructed 
to  urinate  first,  and  thus  clear  away  the  purulent  secretion  as  far  as 
possible,  and  then  to  inject  the  fluid  slowly  and  steadily  into  the 
canal.  Too  great  or  spasmodic  force  is  liable  to  drive  the  fluid — and, 
with  it,  germ  infection — into  the  deep  urethra  and  produce  prostatic, 
vesical,  or  testicular  complications. 

During  the  increasing  stage  of  urethritis,  injections,  if  used  at 
all,  should  be  very  mild — they  may  usually  with  advantage  be  dis- 
pensed with  altogether  at  this  time.  A  solution  of  bichloride  of  mer- 
cury in  a  strength  of  from  1-30,000  to  1-15,000,  in  combination  with 
a  small  amount  of  glycerin,  is  about  the  best  routine  injection  for 
use  at  this  period.  Some  cases  appear  to  be  materially  benefited  by 
it,  but  in  many  it  will  be  found  to  be  too  irritating  and,  temporarily 
at  least,  harmful.  Even  in  the  cases  in  which  it  is  beneficial,  it  ap- 
pears to  lose  its  effect  in  from  two  or  three  to  ten  days,  and  it  be- 
comes necessary  to  substitute  for  it  some  of  the  ordinary  astringents 
in  mild  solution.  It  is  possible  that  its  evil  effects  are  due  to  a  pe- 
culiarly destructive  influence  upon  the  ei)ithelium.  It  is  always  more 
markedly  beneficial  in  simple  than  in  virulent  urethritis. 

It  has  sometimes  occurred  to  the  author  that  astringents  often 
serve  to  prevent  the  normal  evolution  of  urethritis  by  condensing 
the  tissues  and  sealing  ux^ — so  to  speak — the  avenues  of  germ  elim- 
ination. 

In  lieu  of  the  bichloride  injection  during  the  increasing  stage, 
an  anodyne  injection  may  be  given,  the  following  being  useful 
formulae : 


478  LYDSTON — DISEASES  OF  THE  MALE  UEETHRA. 

If     Atropinse sulph gr-ij- 

Bismuthi  subnit 3  iv. 

Muc.  acaciae, 

Aquae  dest aa  §  ij. 

M.    Sig.  Shake  well  and  inject  three  times  daUy. 

^     Tr.  opii.  deod 3  ij.- 

Bismuthi  subnit 3  iv. 

Muc.  acacise, 

Aquae  dest aa  §  ij. 

M.    Sig.   Shake  well  and  inject  three  times  daily. 

]^     Morph.  sulph gr. viij. 

Cocainae gr.  iv. 

Muc.  acacise §  i. 

Aquae  dest q.  s.  ad  §  i j . 

M.    Sig.  Inject  three  times  daily. 

There  is  no  objection  to  the  use  of  a  mild  and  sedative  astringent 
in  combination  with  the  anodynes : 

If     Plumbi  acetatis gr.iv. 

Vini  opii 3  i j  • 

Aqu£B  rosae q.  s.  ad  §  iv. 

M.    Sig.  Inject  three  times  daily. 

I^     Sodii  biboratis gr.  xx. 

Morph.  sulph gr.  vi. 

Aquae  rosae §  iv. 

M.    Sig.  Inject  three  times  daily. 

In  the  stationary  stage  of  the  affection  the  strength  of  the  astrin- 
gent injections  may  be  slightly  increased.  It  would  appear  that  it  is 
not  so  much  the  form  of  astringent  as  the  method  of  its  use  that 
determines  the  beneficial  effects.  It  will  be  found  that  a  number  of 
different  astringents  will  give  about  the  same  average  results  when 
properly  used,  although  in  some  cases  it  will  be  found  necessary  to 
vary  them.  The  most  popular  astringent  drug  is  the  sulphate  of 
zinc,  and  this  will  be  found  beneficial  in  quite  a  large  proportion  of 
cases.  Personally  the  author  prefers  the  sulpho-carbolate  or  iodide 
of  zinc  to  the  sulphate.  The  nitrate  of  silver  in  a  strength  of  one- 
eighth  to  one-half  of  a  grain  to  the  ounce  of  water  is  often  of  great 
service.     Some  recommend  it  as  the  best  routine  injection. 

The  following  illustrative  combinations  will  be  found  to  be  useful : 

If     Zinci  sulphat.  (acetat. ) gr. xij. 

Morph.  sulph gr. x. 

Glycerini 3  i. 

Aquae  rosae %  iij. 

M.    Sig.  Injection. 


RATIONAL   TREATMENT.  479 

IJ     Zinci  sulplio-carb gr.  xvi. 

Glycerini 3  i. 

Aquae  rosse §  iij. 

M.    Sig.  Injection. 

IJ     Zinci  iodidi gr. viij. 

Ac.  carbol gr.iv. 

Aquae  dest §  iv. 

M.    Sig.  Injection. 

Tlie  acetate  of  lead  is  also  a  serviceable  astringent. 

^     Plumbi  acet gr.  xx. 

Tr.  opii 3  ij. 

Aquae  rosae q.  s.  ad  §  iv. 

M.    Sig.  Injection. 

The  vegetable  astringents  are  often  to  be  preferred  to  those  of  a 
mineral  character.  Matico,  hydrastis,  catechu,  kino,  and  like  drugs 
are  very  popular,  and  are  dependent  upon  the  tannic  acid  which  they 
contain.  The  muriate  of  hydrastin  is  especially  popular  and  very 
often  efficacious.  A  favorite  vegetable  astringent  in  the  author's 
practice  is  the  fluid  extract  of  hamamelis  virginica.  The  following 
formula  has  proved  of  great  service : 

I^     Hydrastin  mur gr.  x. 

Ext.  liamamelis  fl 3  ij. 

Glycerini §  i. 

Aquae  dest q.  s.  ad  §  iv. 

M.     Sig.     Injection. 

As  the  inflammation  begins  to  decline,  the  strength  of  the  injec- 
tion selected  may  be  increased,  sometimes  to  double  the  proportions 
given.  This  should  be  done  very  cautiously,  however,  and  in  no 
instance  should  an  injection  be  continued  when  it  is  found  to  produce 
considerable  pain.  Nothing  more  than  a  slight  smarting  is  warrant- 
able. In  some  cases  the  use  of  the  injection  does  not  produce  much 
immediate  discomfoi-t,  but  it  is  fdund  that  smarting  during  micturi- 
tion increases.  Under  such  circumstances  either  the  strength  of  the 
injection  should  be  diminished  or  some  other  form  of  medicament 
substituted  for  it.  This  proposition  is  especially  pertinent  as  applied 
to  injection  of  the  bichloride  of  mercury ;  it  will  be  found  that  with 
this  drug  in  a  strength  of  even  one-sixteenth  of  a  grain  to  the  ounce, 
patients  will  comx)lain  in  a  day  or  two,  not  of  pain  following  the 
injection,  but  of  severe  smarting  in  micturition. 

Sulphate  of  thallin  is  often  of  service  in  a  strength  of  20  grains  to 
the  ounce  of  rose-water. 

Iodoform  has  been  used  to  a  considerable  extent  in  the  treatment 


480  LYDSTON — DISEASES   OF  THE  MALE  URETHKA. 

of  acute  uretliritis,  but,  as  far  as  the  author's  experience  goes,  it  does 
not  seem  to  be  superior  to,  or  even  as  efficacious  as,  many  other 
drugs,  and  its  disagreeable  odor  more  than  counterbalances  any 
possible  beneficial  effects.  In  the  chronic  forms  of  the  disease, 
however,  it  may  be  used  with  advantage,  if  the  patient  can  be  in- 
duced to  disregard  its  tell-tale  odor. 

A  form  of  treatment  which  has  been  highly  recommended  is  the 
insertion  of  soluble  bougies  of  various  types  of  medication.  The 
author  is  satisfied  that  this  method  of  treatment  is  not  only  illogical, 
but  is  very  injurious  in  acute  urethritis,  for  any  suppository  of 
sufficient  stiffness  to  permit  of  its  introduction  into  the  urethra  is 
capable  of  producing  mechanical  irritation.  As  an  additional  ob- 
jection, there  is  no  form  of  soluble  bougie  which  can  be  practically 
applied  by  the  majority  of  patients.  There  exists,  also,  the  not  in- 
considerable danger  of  exciting  inflammation  of  the  deep  urethra, 
prostatic  and  vesical  complications,  and  epididymitis.  The  author 
has  seen  several  of  these  complications  in  consultation,  which  he  has 
been  inclined  to  attribute  to  the  use  of  the  bougies,  and  in  experiment- 
ing with  them  in  his  ow^n  practice  he  has  had  on  several  occasions 
unfortunate  results.  It  is  certain  that  it  is  impracticable  to  combine 
germicide  drugs  with  the  bougies  in  sufficient  strength  to  completely 
neutralize  the  virus  of  the  disease,  and  inasmuch  as  the  bougie 
necessarily  carries  with  it  more  or  less  of  the  poison  into  the  deeper 
portion  of  the  canal,  it  is  obvious  that  an  extension  of  the  inflamma- 
tion is  apt  to  result.  The  author  does  not  wish  to  be  understood  as 
absolutely  condemning  the  use  of  soluble  bougies,  for  in  the  chronic 
forms  of  urethritis  the}"  are  often  of  service.  It  must  be  confessed, 
however,  that  even  in  these  cases  the  bougie  is  of  benefit  chiefly 
through  a  primary  increase  of  irritation  of  the  canal,  as  a  conse- 
quence of  the  mechanical  stimulation  which  it  produces.  The  author, 
therefore,  rarely  uses  them,  excepting  in  exceedingly  chronic  cases 
in  which  he  considers  it  necessary  to  "wake  up,"  so  to  speak,  the 
inactive  mucous  membrane. 

One  of  the  most  popular  modern  methods  of  treatment  of  ure- 
thritis is  that  by  retro-injection  of  hot  water  or  antiseptic  solutions 
through  a  soft  rubber  catheter  or  some  of  the  various  forms  of 
tubes  devised  specially  for  this  purpose.  Many  of  those  who  have 
tried  this  method  are  very  enthusiastic  in  its  praises,  but  the  author 
is  free  to  say  that  these  surgeons  must  either  have  a  knack  in  the 
application  of  the  method  which  he  has  been  unable  to  acquire, 
or  his  patients  are  characterized  by  very  sensitive  urethras.  The 
method  is  open  to  the  same  objections  as  the  use  of  soluble  bougies,  for 
in  the  introduction  of  the  tube  more  or  less  of  the  virus  is  carried  into 


CHEONIC   URETHRITIS.  481 

the  deeper  portions  of  the  canal,  and  it  is  questionable  whether  the 
injection  fluid  can  be  safely  given  in  a  strength  sufficient  to  neutralize 
it.  More  or  less  mechanical  irritation  is  induced,  and  in  very  acute 
cases  this  is  likely  to  be  jjroductive  of  injury.  On  the  other  hand, 
in  certain  cases  which  exhibit  a  tendency  to  chronicity  the  irrigation 
method  is  decidedly  beneficial. 

The  author  has  found  that  a  soft,  open-ended  catheter  is  as  useful 
as  anything  for  deep  irrigation  of  the  urethra.  Under  ordinary  cir- 
cumstances, and  always  in  acute  cases,  a  short  nozzle  is  sufficient. 
This  is  to  be  used  without  a  urethral  tube,  and  has  a  concave  shield 
to  catch  the  return  flow.  There  are  several  varieties  of  injection 
tubes  which  are  more  or  less  useful. 

The  latest  fad  in  the  treatment  of  urethritis  is  what  is  termed  the 
dry  method.  This  consists  in  the  introduction  of  dry  antiseptic 
powders  into  the  canal  through  a  special  and  patented  device.  This 
method  is  open  to  the  same  objections  as  is  the  use  of  soluble  bougies 
and  retro-irrigation  in  acute  gonorrhoea.  It  is  apt  to  be  of  service, 
however,  in  less  acute  forms  of  the  disease. 

Blistering  the  perineum  and  penis  by  means  of  cantharidal  solu- 
tion is  a  favorable  remedy  for  acute  gonorrhoea  with  some  surgeons. 
Milton,  in  particular,  favors  this  method  of  treatment,  but  applies  the 
blister  in  the  form  of  cantharidal  plaster  wrapped  about  the  penis. 
The  author  has  found  that  most  patients  object  to  fly-blisters,  and 
has  compromised  by  applications  of  the  tincture  of  iodine  along  the 
course  of  the  urethra  with  apparent  benefit.  Milton  recommends 
what  he  terms  a  "  caustic  plug"  in  the  treatment  of  obstinate  cases  of 
gonorrhoea.  This  consists  in  a  strip  of  linen,  saturated  in  a  five- 
grain  solution  of  nitrate  of  silver,  which  is  inserted  into  the  urethra 
through  a  tube  similar  to  an  endoscope ;  the  latter  is  then  removed, 
the  cloth  being  allowed  to  remain  until  it  comes  away  with  the  urine. 

It  is  not  the  writer's  purpose  to  present  all  of  the  various  methods 
of  treatment  and  specifics  that  have  been  recommended  for  ure- 
thritis. This  would  be  an  onerous  as  well  as  unprofitable  task.  The 
list  of  specifics  recommended  runs  well  into  the  hundreds.  The  fore- 
going is  intended  only  as  a  practical  outline  of  urethral  therapeutics. 

Chronic  Urethritis. 

Chronic  urethritis  embraces  all  those  various  phases  of  secretion- 
forming  inflammations  of  the  urethra  which  are  generally  included 
under  the  generic  term  of  gleet.  For  the  sake  of  accuracy,  the  latter 
term— if  it  be  used  at  all— should  be  applied  with  the  understanding 
that  it  merely  implies  a  symptom,  and  only  to  those  chronic  forms  of 
Vol.  I.— 31 


482  LYDSTON— DISEASES   OF  THE  MALE  UKETHEA. 

inflammation  which  come  on,  at  a  greater  or  less  interval  after  tlie 
acute  urethritis  is  apparently  cured,  as  a  consequence  of  various 
pathological  changes  of  a  chronic  character  clue  to  the  antecedent 
acute  inflammation.  It  is  better,  however,  to  use  the  term  first  sug- 
gested. 

Causes. 

The  causes  of  chronic  urethritis  are  as  follows : 

1.  Idiosyncrasy.  This  consists  in  this  instance  of  a  predisposi- 
tion to  mucous  fluxes  and  catarrhs  characterizing  certain  individ- 
uals. This  is  a  particularly  important  factor  in  certain  climates. 
The  variable  temperature  and  barometric  pressure  characterizing  our 
lake  region  are  an  illustration  of  this,  and  seem  to  have  an  influence 
in  aggravating  and  perpetuating  urethritis. 

2.  The  gouty  and  rheumatic  diatheses. 

3.  Dyscrasise  of  various  kinds,  particularly  syphilis. 

4.  Cachectic  conditions  resulting  from  various  constitutional  dis- 
eases of  an  acute  or  chronic  character. 

5.  Intemperance  in  eating  and  drinking. 

6.  Improper  treatment,  invoMng  usually  the  use  of  too  powerful 
injections,  with  resultant  destruction  of  the  epithelium  of  the  mucous 
membrane. 

7.  Too  active  exercise  during  the  acute  stage  of  urethritis. 

8.  Prolonged  and  ungratified  sexual  desire. 

9.  Sexual  excesses  and  masturbation. 

10.  Privations  of  various  kinds  and  unhealthy  hygienic  surround- 
ings. 

11.  Localization  of  the  acute  inflammation  at  some  particular 
point,  with  a  consequent  patch  of  local  disease  involving  stricture  or 
a  granular  and  congested  condition  of  the  mucous  membrane.  This 
is  the  most  important  factor  of  all. 

It  will  be  observed  from  a  survey  of  these  various  causes  that  the 
influences  which  tend  to  the  perpetuation  of  urethritis  are  numerous 
and  varied. 

Vaeeetees  of  Chronic  Ukethritis. 

Chronic  urethritis  presents  itself  under  three  different  forms : 
1.  The  acute  inflammation  subsides  to  a  certain  extent,  but  re- 
mains subacute,  with  occasional  acute  exacerbations  accompanied  by 
a  thick,  purulent  discharge  for  an  indefinite  period.  In  this  form  of 
chronic  inflammation  there  is  continual  discomfort,  with  more  or  less 
pain  and  smarting  on  urination.     Generally,  too,  the  prostate  is  in- 


VARIETIES   OF   CHRONIC    URETHRITIS.  483 

volved    to  a  certain  extent,   giving  rise  to  a  feeling  of  fulness  and 
tension  in  the  perineum,  with,  frequent  urination. 

2.  The  discharge  becomes  thin  and  watery,  being  sometimes  so 
scanty  that  nothing  is  visible  save  a  drop  or  two  of  muco-purulent 
fluid  escaping  from  the  meatus  in  the  morning.  This  is  the  most 
frequent  form  of  the  disease,  and  is  not  usually  attended  by  discom- 
fort. It  may  depend  upon :  (a)  A  simple  catarrhal  condition  of  the 
mucous  membrane,  such  cases  involving  the  element  of  constitutional 
and  local  predisposition.  (6)  Congested  and  granular  patches  in  the 
mucous  membrane,  (c)  Organic  stricture,  (d)  Urethral  polypi  and 
papillomata.  These  are  very  rare  conditions,  but  cases  in  which 
polypoid  growths  were  removed  through  the  endoscope  are  reported  by 
Griinfeld  and  others.  The  author  has  operated  several  times  for 
urethral  papillomata  with  a  resulting  cure  of  obstinate  gleet,  (e)  Ab- 
scesses or  fistulae  resulting  from  acute  urethritis,  and  becoming 
chronic.  (/)  Dilatation  and  pocketing,  with  chronic  inflammation  of 
the  lacuna  magna.  (g)  Urethro-prostatic  catarrh.  (h)  Posterior 
urethritis,  i.e.,  chronic  follicular  prostatitis.  (^)  Folliculitis.  (j) 
Cowperitis.      (k)   Tubercular  infection. 

3.  In  this  form  of  chronic  urethritis  the  inflammation  is  ajjpar- 
ently  recovered  from,  but  after  a  variable  period  of  time,  during  which 
possibly  the  individual  does  not  have  his  attention  called  to  his  ure- 
thra, there  develops,  as  a  consequence  of  sexual  excesses,  intemper- 
ance, or  the  like,  a  thin  muco-purulent  discharge. 

The  distinctive  features  of  the  various  phases  of  chronic  urethritis 
are  dependent  upon  differences  in  the  degree  of  activity  of  the  inflam- 
matory process ;  such  differences  do  not  warrant  a  distinct  differen- 
tiation of  chronic  urethritis  and  gleet.  As  a  rule,  however,  the  dan- 
ger of  contagion  is  directly  x^roportionate  to  the  degree  of  purulency 
of  the  discharge.  It  must,  however,  be  considered  in  this  connection 
that,  as  already  suggested,  it  is  possible  that  the  discharge  of  virulent 
urethritis  may  lose  its  purulent  and  ordinary  infectious  qualities  as 
far  as  its  capacity  for  imparting  acute  vaginitis  is  concerned,  but 
may  nevertheless  become  transformed  in  such  a  manner  that  it  is  still 
capable  of  setting  up  various  uterine,  peri-uterine,  salpingian,  and 
ovarian  troubles  in  the  female. 

Some  of  the  cases  of  so-called  gleet  consist  in  the  appearance, 
under  sexual  excitement,  and  almost  uniformly  on  rising  in  the  morn- 
ing, of  a  slight,  sticky  moisture  at  the  meatus.  In  most  of  these 
cases  the  annoyance  produced  by  the  disease  is  entirely  of  a  mental 
character.  The  author  is  sometimes  inclined  to  think  that  such  pa- 
tients  would  experience  a  feeling  of  disappointment  if  they  failed  to 
detect  on  rising  in  the  morning  the  usual  tear  of  urethral  secretion. 


484  LYDSTON — DISEASES   OF  THE   MALE   URETHEA. 

The  appellation  of  psycliic  gleet,  although  a  little  far-fetched,  would 
not  be  inappropriate  as  applied  to  such  cases.  Some  of  these  pa- 
tients are  unable  to  detect  the  secretion,  except  on  squeezing  the  ure- 
thra. The  pertinacity  with  which  such  individuals  will  vigorously 
"  milk"  the  urethra  for  the  purpose  of  exhibiting  a  drop  or  two  of 
mucus  as  an  evidence  of  their  alleged  deplorable  condition  is  worthy 
of  a  better  cause.  Probably  fifty  per  cent,  of  these  cases  are  kept  up 
by  this  pernicious  practice.  Most  individuals,  upon  being  ques- 
tioned, will  acknowledge  that  they  are  in  the  habit  of  seeking  for  the 
discharge  a  number  of  times  daily,  and  they  are  considerably  sur- 
prised when  informed  that  their  enthusiastic  search  for  something 
that  they  do  not  wish  to  find,  is  mainly  responsible  for  their  woes. 
The  pathological  condition  in  this  variety  of  gleet  is  simple  hyper- 
secretion of  mucus  by  the  follicles  of  the  urethra.  The  author  is  con- 
vinced, moreover,  that  quite  a  proportion  of  cases  in  which  the  dis- 
charge is  more  pronounced  are  dependent  upon  a  catarrhal  state  of 
the  mucous  membrane,  with  a  coincident  hypersecretion  of  mucus,  as 
a  result  (1)  of  habitual  over-stimulation  of  the  glands  and  (2)  of 
their  enlargement. 

The  discharge  in  most  cases  is  thin,  rather  watery,  and  of  a  whit- 
ish color.  It  becomes  thick  and  yellowish,  however,  under  the  in- 
fluence of  the  various  causes  enumerated  as  productive  of  chronic 
urethritis.  A  patient  suffering  with  gleet  is  continually  liable  to 
acute  exacerbations  of  his  urethral  difficulty  upon  the'  occurrence  of 
the  slightest  exciting  cause.  The  origin  of  the  discharge,  in  cases 
in  which  no  local  lesion  of  the  urethral  mucous  membrane  can  be 
discovered,  is  the  numerous  mucous  follicles  lining  that  portion  of 
the  urethra  corresponding  to  the  site  of  the  chronic  inflammation. 
There  is  more  or  less  epithelium  mingled  with  the  discharge,  and  it 
will  be  found  that  one  of  the  characteristic  features  of  gleet  is  a  rapid 
formation  and  removal  of  the  delicate  epithelial  cells  lining  the  ure- 
thra. This  is  particularly  pertinent  as  applied  to  those  cases  of 
chronic  inflammation  dependent  ux)on  chemical  or  traumatic  interfer- 
ence with  the  canal,  such  as  is  afforded  by  strong  injections  and  in- 
judicious instrumentation.  When  congested,  granular,  or  abraded 
patches  exist  in  the  course  of  the  canal,  there  is  a  constant  hyper- 
secretion of  mucus  or  muco-pus,  with  exfoliation  of  the  epithelium 
upon  the  surface  of  the  lesion.  In  this  condition,  as  well  as  in  stric- 
ture, the  current  of  urine,  as  it  passes  over  the  diseased  portion  of 
the  canal,  rolls  up  into  strings  or  threads  the  desquamated  epithelium 
and  muco-purulent  deposit  upon  the  surface  of  the  diseased  mem- 
brane. These  strings  appear  in  the  urine  as  the  delicate  thready 
filaments — Tripper-faden — which,  as  every  practical  surgeon   is  well 


VARIETIES  OF  CHRONIC  URETHRITIS.  485 

aware,  are  almost  invariably  indicative  of  urethral  disease.  The 
majority  of  surgeons  attribute  this  appearance  of  the  urine  to  stric- 
ture, but  this  is  a  mistake,  for  it  will  be  found  in  many  cases  in 
which  stricture  cannot  be  detected,  and  is  in  such  cases  dependent 
upon  urethral  catarrh  and  general  desquamation  of  epithelium.  In 
stricture  a  condition  of  chronic  inflammation  exists  posterior  to  the 
narrowing  of  the  canal ;  as  a  consequence  of  obstruction  at  this  point 
there  is  more  or  less  pouching  of  the  urethra  at  the  posterior  surface 
of  the  stricture.  This  dilated  portion  of  the  canal  loses  its  elasticity 
and  contractility,  and,  as  a  consequence,  forms  a  more  or  less  passive 
pouch  upon  its  floor,  in  which  a  drop  or  two  of  urine  almost  invari- 
ably remains  and  decomposes.  As  a  consequence  of  this  decompo- 
sition, the  inflammation  and  consequent  muco-purulent  secretion 
are  enhanced.  It  is  from  this  point  that  the  gleety  discharge  and 
thready  urinary  filaments  characterizing  stricture  are  derived. 

The  author  desires  to  emphasize  particularly  the  influence  of 
powerful  injections  in  the  production  of  chronic  urethritis.  He  has 
had  a  number  of  cases  come  under  his  observation  in  which  the  pa- 
tients had  used  powerful  solutions  of  carbolic  acid,  sulphate  of  zinc, 
permanganate  of  potassium,  etc.,  in  the  early  stages  of  urethritis,  and 
in  the  majority  of  these  cases  he  has  had  an  endless  amount  of  trouble 
in  curing  the  disease.  The  obstinacy  of  such  cases  is  undoubtedly 
dependent  upon  chemical  destruction  of  the  epithelium  lining  the 
canal.  This,  being  repeated  from  day  to  day,  eventually  results  in  a 
permanently  abraded  condition  of  the  entire  mucous  membrane, 
which  necessitates  the  rapid  proliferation  of  epithelium  for  the  pur- 
pose of  repair ;  this  ej)ithelium  being,  however,  of  a  low  grade  and, 
moreover,  governed  to  a  certain  extent  by  the  influence  of  physio- 
logical habit,  is  thrown  off  as  rapidly  as  formed,  and,  as  a  result,  the 
canal  remains  in  a  perpetually  raw  and  inflamed  condition.  It  is  by 
no  means  necessary  that  injections  should  be  acutely  painful  when 
used  to  accomplish  this  untoward  result. 

Still  more  important  factors  in  the  production  of  chronic  ure- 
thritis are  intemperance  and  faulty  sexual  hygiene.  The  use  of  alco- 
hol predisposes  all  of  the  tissues  of  the  body  to  inflammatory  pro- 
cesses, this  being  particularly  true  of  the  mucous  membranes,  which 
become  highly  irritable;  it  has,  moreover,  a  special  effect  in  over- 
stimulation of  the  sexual  apparatus,  both  through  the  medium  of  the 
nervous  system  and  more  directly  by  the  production  of  irritating 
I)roperties  in  the  urine.  The  majority  of  individuals  contracting 
urethritis  are  more  disturbed  by  the  interruption  of  their  customary 
fornication  than  by  any  immediate  or  remote  danger  or  inconveni- 
ence produced  by  the  disease.     They  are  i^ossessed  also  with   the 


486  LYDSTON — DISEASES   OP  THE   MALE   UEETHRA. 

fatuitous  idea  that  any  form  of  sexual  stimulation  sliort  of  actual 
intercourse  is  not  injurious;  as  a  consequence,  they  associate  inti- 
mately with  women  of  loose  character,  whom  they  can  caress  and 
take  liberties  with,  and,  as  a  result,  keep  the  sexual  system  in  a  con- 
stant state  of  excitement.  This  is  fully  as  disastrous  in  its  effects  as 
natural  sexual  indulgence,  if,  indeed,  it  is  not  worse.  As  soon  as 
our  patients  are  satisfied  that  a  discharge  no  longer  exists,  or,  in 
many  instances,  as  soon  as  the  discharge  has  greatly  diminished  in 
quantity,  they  begin  their  sexual  indulgences.  They  come  to  us  in 
the  fault-finding  manner  of  the  average  venereal  patient,  and  ascribe 
the  unfavorable  progress  of  the  urethritis  to  improper  treatment; 
seldom  will  they  acknowledge  sexual  excitement  or  indulgence,  or 
the  use  of  alcoholic  beverages.  Were  it  not  for  the  sexual  and  alco- 
holic elements  in  the  production  of  gleet,  the  author  is  satisfied 
that  comparatively  few  cases  of  urethritis  would  last  over  six  or  eight 
weeks. 

A  lack  of  rest  is  another  important  element  favoring  chronic  ure- 
thritis. In  every  case  of  virulent  inflammation  in  which  the  patient 
is  so  situated  that  he  is  compelled  to  be  on  his  feet  the  greater  part 
of  the  time,  to  walk  about  or  indulge  in  muscular  strains,  lifting, 
etc.,  we  may  expect  a  stubborn  course  of  the  disease.  As  a  corollary, 
it  is  to  be  inferred  that  patients  enjoying  facilities  for  comparative 
quiet  will  recover  promj)tly  in  the  majority  of  instances. 

Duration. 

The  duration  of  chronic  urethritis  is  very  uncertain ;  it  depends 
mainly  upon  the  curability  of  the  various  pathological  conditions  of 
the  canal  uj^on  which  the  perpetuation  of  the  chronic  urethral  inflam- 
mation depends.  In  some  instances,  a  complete  cure  is  impossible, 
judging  by  the  frequency  with  which  cases  are  encountered  that  have 
undergone  every  known  method  of  treatment  for  a  number  of  years 
without  success.  The  author  ventures  the  opinion  that,  in  such  an 
environment  as  our  lake  region,  catarrhal  urethritis  is  more  apt  to 
persist  indefinitely  than  in  other  localities. 

Some  cases  of  alleged  gleet  cannot  be  cured  simply  because  of  the 
pertinacity  with  which  the  patient  clings  to  the  idea  that  he  is  in  a 
serious  condition,  ove^-treatment  being  the  most  natural  result.  One 
meets  with  numerous  cases  in  which  the  patient  is  practically  cured, 
but  in  which  it  is  impossible  to  convince  him  that  such  is  the  case. 
These  cases  of  psychopathic  gleet  go  from  surgeon  to  surgeon,  vainly 
seeking  a  cure  for  something  which  does  not  exist. 

Too  prolonged  and  energetic  treatment  is  often  responsible  for  the 


TREATMENT   OF   CHRONIC   URETHRITIS.  487 

perpetuation  of  gleet.     Many  cases  are  observed  in  which  improve- 
ment occurs  only  upon  complete  cessation  of  treatment. 

Cases  of  gleet  are  occasionally  seen  that  defy  all  measures  of 
treatment. 

Treatment. 

The  treatment  of  chronic  urethritis  requires  more  radical  meas- 
ures than  are  warrantable  in  the  acute  stages  of  the  affection,  and 
incidentally  a  greater  variety  of  remedies,  these  being  necessitated 
by  the  varying  character  of  the  special  causes  Mdiich  tend  to  the  per- 
petuation of  the  inflammation. 

The  first  step  to  be  taken  is  to  explore  the  urethra,  and  thus  de- 
termine, if  possible,  what  particular  local  condition  is  keeping  up 
the  difficulty.  For  ordinary  purposes  the  bulbous,  flexible  French 
bougies  will  be  found  to  be  all  that  is  necessary  for  this  purpose,  for 
in  the  majority  of  instances  a  knowledge  of  the  existence  of  a  local- 
ized spot  of  inflammation  or  stricture  is  all-sufficient,  ocular  inspec- 
tion being  of  little  or  no  advantage.  In  the  hands  of  the  expert  the 
bulbous  bougie  readily  determines  with  a  great  degree  of  accuracy 
the  condition  of  the  urethra.  Otis'  acorn-tipped  metallic  sounds  may 
be  used,  but  the  soft  instruments  are  preferable. 

The  endoscope  bears  a  somewhat  similar  relation  to  urethral  ex- 
ploration that  the  stethoscope  does  to  the  diagnosis  of  disease  of  the 
thoracic  viscera.  The  physician  who  becomes  expert  in  physical 
diagnosis  finds  that  the  unaided  ear  is  all-sufficient  for  practical  pur- 
poses in  the  exploration  of  the  chest,  the  stethoscope  becoming  nec- 
essary only  in  very  obscure  cases,  or  those  in  which  critical  and 
hair-splitting  differentiation  of  objective  signs  becomes  necessary. 
There  have  been  numerous  elaborate  endoscopes  devised,  but  for 
practical  purposes  the  ordinary  straight,  hard  rubber  or  silver  tubes, 
with  the  addition  of  a  strong  light  reflected  from  a  laryngoscopic  re- 
flector, or  from  one  of  the  modern  small  reflecting  electric  lamps,  are 
sufficient.  The  panelectroscope  of  Leiter  is  valuable  where  it  is 
practicable  to  utilize  it.  The  author  has  found  that  his  own  endo- 
scopic tubes,  which  are  much  larger  than  Leiter's,  are  more  useful 
than  the  latter  in  most  cases  in  which  he  uses  the  panelectroscope. 
It  is  well  to  have  a  series  of  these  tubes,  in  order  that  an  instrument 
may  be  selected  which  is  as  large  as  the  capacity  of  the  urethra  will 
permit. 

In  case  stricture  exists,  i^reliminary  dilatation  may  always  be 
I)ractised  jjrior  to  endoscopy,  and  it  thus  becomes  x>ossible  to  use 
relatively  large  tubes  for  explorative  purposes.  The  mistake  is 
often  made  of  having  tliese  tubes  made  too  long;  by  crowding  the 


LYDSTON — DISEASES   OF   THE   MALE   URETHRA. 

penis  well  down  around  the  tube,  a  short  tube  can  be  used  mucli 
more  effectively  than  larger  ones. 

We  will  first  consider  those  cases  the  chronicity  of  which  depends 
chiefiy  upon  constitutional  conditions  or  a  general  predisposition  to 
catarrhal  fluxes  of  various  kinds,  and  in  which  exploration  fails  to 
detect  any  local  condition  that  will  explain  the  discharge.  Cases 
frequently  arise  in  which  all  forms  of  internal  and  local  treatment  fail 
of  their  object  because  of  inappreciation  of  the  constitutional  pecu- 
liarities of  the  patient.  Debilitated  and  strumous  subjects,  and 
those  who  are  cachectic  from  any  cause  whatever,  require  the  admin- 
istration of  tonics,  such  as  quinine,  iron,  cod-liver  oil,  and  various 
preparations  of  nux  vomica.  In  cases  of  this  kind  the  tincture  of  the 
chloride  of  iron  or  the  mineral  acids  sometimes  accomplish  wonderful 
results  by  improving  the  general  systemic  condition,  toning  up  the 
relaxed  and  flabby  mucous  membranes,  and  inhibiting  excessive 
secretion.  It  is  in  these  cases,  too,  that  we  are  apt  to  have  excellent 
results  from  the  internal  administration  of  vegetable  astringents, 
ergot,  etc.  Turpentine  in  moderate  doses  is  occasionally  of  decided 
advantage  to  these  patients ;  the  tincture  of  cantharides  may  also  be 
of  service. 

Local  measures  of  treatment  are  often  unnecessary.  In  fact,  it 
will  be  found  that  it  is  in  just  such  patients  that  the  prolonged  use 
of  injections  and  balsamic  preparations  are  inclined  to  j)erpetuate  the 
gleet.  In  some  instances,  however,  in  conjunction  with  measures  to 
improve  the  general  health,  it  will  be  found  advantageous  to  make 
local  applications.  One  of  the  best  preparations  is  the  pure  fluid 
extract  of  hamamelis,  applied  by  a  cotton- wrapped  i)robe  through  the 
endoscopic  tube.  This  will  never  be  found  to  be  too  strong,  and  it 
is  a  singular  circumstance  that  patients  who  are  unable  to  bear  an 
ordinary  injection,  in  the  strength  of  one  part  of  hamamelis  to  four 
of  water,  make  no  complaint  of  the  application  of  the  pure  fluid  ex- 
tract in  this  nianner.  It  is  sometimes  necessary  to  alternate  the 
applications  of  this  astringent  with  the  use  of  an  ointment  of  nitrate 
of  silver,  ten  grains  to  the  ounce,  in  combination  with  stramonium 
or  belladonna,  by  means  of  the  cupi^ed  sound.  Tannin  may  be  used 
in  the  same  manner.  In  making  all  these  applications  the  patient 
should  first  be  directed  to  urinate ;  a  full-sized  sound  should  then  be 
passed  to  press  out  the  contents  of  the  dilated  follicles  of  the  urethra, 
after  which  the  medicated  application  is  made. 

A  plan  which  has  proved  efficacious  in  some  instances  is  the  pro- 
longed use  of  hot  water  in  combination  with  the  acetate  of  lead,  the 
patient  being  instructed  to  inject  the  urethra  for  fifteen  or  twenty 
minutes,  night  and  morning,  with  water  as  hot  as  can  be  borne.    The 


TREATMENT  OP  CHRONIC   URETHRITIS.    .  489 

treatment  is  to  be  concluded  by  syringing  the  canal  with  fifteen  drops 
of  a  saturated  solution  of  the  acetate  of  lead  in  an  ordinary  teacujoful 
of  hot  water.  This  is  to  be  thrown  into  the  canal  four  or  five  times 
in  succession.  In  a  few  instances  of  catarrhal  gleet  the  author  has 
succeeded  in  checking  the  discharge  by  the  use  of  a  watery  solution 
of  ordinary  alum,  in  the  strength  of  a  drachm  to  eight  ounces,  night 
and  morning. 

It  may  be  considered  absurd  to  advocate  a  change  of  climate  for 
patients  with  this  form  of  chronic  urethritis,  yet,  when  the  general 
condition  seems  to  demand  it,  this  plan  may  be  advised,  and  will  be 
found  to  be  productive  of  marked  benefit. 

The  rheumatic,  gouty,  syphilitic,  and  tubercular  diatheses  will 
be  found  to  be  responsible  for  some  cases  of  chronic  urethritis. 
These  conditions  require  the  same  remedies  as  under  other  circum- 
stances ;  the  combinations  of  mercury,  iodide  of  potassium,  and  col- 
chicum  are  apt  to  be  particularly  serviceable  in  the  three  former 
conditions.  The  various  balsamic  preparations  may  be  continued 
during  the  course  of  treatment  for  chronic  urethritis,  providing  the 
stomach  and  kidneys  are  tolerant  of  these  drugs. 

Stricture  of  the  urethra  is  the  most  frequent  cause  of  chronic  ure- 
thritis.    Its  treatment  will  be  considered  in  a  subsequent  section. 

Congested  and  granular  patches  require  local  applications  by 
means  of  the  endoscopic  tube.  It  should  be  remembered  in  this  con- 
nection that  general  and  powerful  applications  to  the  canal  are  apt  to 
be  productive  of  injury.  It  is  an  unfortunate  fact  that  the  surgeon 
seldom  localizes  his  efforts  to  cure  the  complaint,  but  continues  the 
use  of  caustic  and  astringent  applications,  "shot-gun"  fashion — 
sometimes  hitting  the  disease,  but  more  often  the  normal  membrane 
— and  the  internal  administration  of  the  balsams,  in  a  futile  effort  to 
relieve  something  that  perhaps  a  single  well-directed  application 
would  cure.  It  is  necessary  to  determine  the  precise  location  of 
the  offending  spot  and  to  measure  accurately  its  distance  from  the 
meatus,  with  or  without  ocular  inspection  of  the  part.  The  passage 
of  a  steel  sound  upon  alternate  days  for  a  few  weeks  will  cure  a 
large  proportion  of  these  cases  by  crushing  the  minute  granulations, 
emxjtying  pus-distended  follicles,  producing  local  absorption  of  the 
infiltrated  material  in  the  mucous  membrane,  toning  up  the  latter,  and 
stimulating  rei)air.  When  this  method  of  treatment  has  been  proven 
to  be  ineffectual,  strong  ai)plications  of  the  nitrate  of  silver  or  the 
sulj^hate  of  copper  may  be  made  directly  to  the  diseased  spot  through 
the  endoscope.  The  pure  crayon  of  sulphate  of  copper  or  nitrate  of  sil- 
ver is  safe,  if  very  cautiously  used.  The  silver  may  be  fused  upon 
the  end  of  a  blunt  i)robe  and  touched  to  the  spot  very  lightly.     In 


490  L¥DSTON — DISEASES   OF   THE   MALE   URETHRA. 

lieu  of  the  pure  caustic,  strong  solutions  of  copj)er  or  silver  may  be 
used,  thirty  to  sixty  grains  to  the  ounce  being  admissible,  but  great 
care  is  necessary  not  to  leave  an  excess  of  the  caustic  fluid  upon  the 
mucous  membrane.  When  the  diseased  point  is  within  three  inches 
of  the  meatus,  the  urethral  speculum  is  often  serviceable  in  making 
applications.  The  meatoscope  may  also  be  useful.  It  is  in  cases 
of  chronic  urethritis  that  the  methods  of  treatment  by  soluble 
bougies  and  retro-injection  are  ajjt  to  prove  of  the  greatest  service. 

One  of  the  oldest  methods  of  treatment  of  gleet  consists  in  the  in- 
jection of  astringents  of  gradually  increasing  strength.  Thus  Ricord's 
old  formula  consists  in  the  injection  of  one  j)art  of  red  wine  to  three 
of  water,  each  syringeful  of  the  injection  being  replaced  by  wine,  so 
that  after  a  time  the  patient  is  using  the  pure  red  wine.  Bumstead 
speaks  highly  of  strong  solutions  of  the  persulphate  of  iron. 

Experience  has  sho'mi  that  many  cases  of  urethritis  are  perj^etu- 
ated  by  a  contracted  meatus,  behind  which  urine  and  inflammatory 
products  accumulate  and  produce  irritation.  It  is  advisable  to  per- 
form meatotomy  as  a  matter  of  routine  in  every  case  of  chronic  ure- 
thritis in  which  the  meatus  will  not  admit  a  full-sized  sound.  The 
incision  should  be  made  with  a  straight  blunt-pointed  bistourj'^  and 
kept  open  by  the  frequent  introduction  of  a  short  sound  or  a  fossal 
bougie. 

In  some  cases  of  gleet,  dependent  upon  congested  and  granular 
patches  of  mucous  membrane,  there  exists  a  slight  thickening  of  the 
underlying  mucous  membrane,  hardly  of  sufficient  importance  to  be 
denominated  a  stricture,  yet  requiring  the  same  treatment,  and  even- 
tually terminating  in  a  constriction  of  the  lumen  of  the  canal.  These 
patches  of  tough  and  resilient  infiltration  are  usually  found  in  the 
pendulous  portion  of  the  urethra,  and  in  such  cases  the  gleet  is  abso- 
lutely resistant  to  all  measures  of  treatment,  until  a  urethrotomy  is 
made  and  the  thin  layer  of  thickened  tissue  divided.  When  this 
process  extends  entirely'  around  the  circumference  of  the  canal,  it 
necessarily  constitutes  a  stricture  of  large  calibre,  but  it  is  well  to 
remember  that  the  relation  of  the  thickened  tissue  to  the  gleet  is 
precisely  the  same  in  those  cases  in  which,  on  account  of  the  circum- 
scribed limitation  of  the  process,  no  pronounced  narrowing  of  the 
canal  is  evident,  as  it  is  in  those  in  which  an  acknowledged  stricture 
exists.  It  is  to  be  remembered,  furthermore,  that  in  many  cases  which 
are  denominated  "  stricture  of  large  calibre"  there  is  really  not  a  stric- 
tured  condition  of  the  canal,  but  as  the  instruments  pass  over  a  thick- 
ened, granular,  and  hypersesthetic  patch  there  occurs,  just  at  the 
location  of  the  lesion,  spasm  of  the  accelerator  urinse  and  com- 
pressor urethrse  muscles,  which  gives  rise   to   the   same    objective 


TREATMENT  OF  CHRONIC   URETHRITIS.  491 

symptoms  as  stricture.  It  is  probable  that  urethrotomy  is  performed 
many  times  for  the  relief  of  strictures  of  large  calibre  in  which  true 
organic  stricture  does  not  exist,  and  there  is  only  the  condition  of 
affairs  just  described  to  explain  the  obstruction  to  the  introduction 
of  instruments  and  the  grasping  of  the  bulbous  bougie  as  it  is  with- 
drawn from  the  canal.  This  fact,  however,  is  no  argument  against 
the  necessity  for  urethrotomy. 

In  a  few  cases  of  chronic  gleet  the  author  has  obtained  marked 
benefit  by  the  use  of  astringent  sprays  thrown  through  the  endoscopic 
tube  by  means  of  an  ordinary  Sass  spray  apparatus,  in  alternation 
with  applications  by  means  of  the  powder-blower  of  an  impalpable 
powder  of  iodoform,  boracic  acid,  and  camphor  in  equal  parts. 

When  the  inflammatory  process  has  extended  to  the  deep  or  pros- 
tatic urethra,  deep  injections  by  some  method  or  other  are  abso- 
lutely necessary.  The  instrument  of  Ultzmann  or  its  modifications 
may  be  used  for  this  purpose.  The  author  has  devised  a  more  capa- 
cious syringe  than  that  of  Ultzmann,  which  he  prefers  to  any  he  has 
seen.  Nitrate  of  silver,  sulphate  of  co^Dper,  and  sulphate  of  thallin 
are  the  best  drugs  for  use  in  these  cases  of  deep  inflammation.  Sol- 
uble prostatic  bougies  and  astringent  ointments  are  occasionally  of 
great  service  in  posterior  urethritis,  i.e.,  follicular  prostatitis. 

As  far  as  his  own  experience  goes,  the  author  has  found  the  sul- 
phate of  thallin  in  a  fifteen  to  twenty  per  cent,  solution  the  best  anti- 
septic and  astringent  application  for  routine  use  in  the  posterior  ure- 
thra. His  usual  plan  is  to  alternate  the  thallin  with  irrigations  of 
nitrate  of  silver  or  potassium  permanganate  in  varying  strength.  In 
some  cases  in  which  there  is  chronic  inflammation  of  the  bulbous 
urethra  we  may  succeed  in  exciting  healthy  action  by  irrigating  the 
canal  with  hot  iodized  water  of  the  strength  of  one  drachm  to  the  pint. 
In  quite  a  number  of  obstinate  cases  the  author  has  had  excellent 
results  from  the  use  of  a  mixture  of  balsam  of  Peru,  compound  tinc- 
ture of  benzoin,  and  iodoform  introduced  through  the  endoscopic  tube : 

5     lodoformi 3  iv. 

Tincturae  benzoini  compositse, 

Balsami  peruv aa   |  i. 

M. 

The  following  is  also  useful  applied  in  the  same  manner :  • 

I^     lodi  resub gr.  xx. 

Eucalyptol 3  i j . 

Potassii  iodidi 3  i j . 

Glycerini  tannat §  ss. 

Ac.  carbol gr.  xx. 

Boroglyceride q.  s.  ad  §  ij. 

M. 


492  LYDSTON — DISEASES  OF  THE  MALE  URETHRA. 

All  measures  of  treatment  of  chronic  gleet  will  fail  if  the  surgeon 
does  not  advise  his  patient  against  various  sexual,  dietetic,  and  other 
general  causes  of  j)erpetuation  of  urethritis,  and  if  the  patient  does 
not  follow  these  instructions  to  the  very  letter.  It  is  an  unfortunate 
fact  that  the  average  patient  with  chronic  urethral  disease  lays  the 
responsibility  of  his  case  upon  the  shoulders  of  his  surgeon,  and  ex- 
pects a  cure  to  be  accomplished  without  the  slightest  co-operation 
upon  his  own  part.  The  capacity  for  deceit  on  the  part  of  the  average 
patient  with  chronic  urethral  disease  is  something  astonishing.  It  is 
certainly  a  discouraging  thing  to  have  a  patient  present  himself  with 
an  acute  or  subacute  urethritis  a  month  or  six  weeks  after  he  has 
apparently  been  cured  of  stricture  and  gleet,  and  have  him  solemnly 
vow  that  he  has  not  played  the  glutton  or  roue  during  that  time.  It 
is  possible  that  a  few  such  patients  do  not  lie  to  the  doctor,  but  it 
would  be  difficult  to  convince  the  expert  that,  in  the  absence  of  an 
exciting  cause,  a  canal  which  had  been  thoroughlj^  dilated  and  the 
secretion  of  which  had  been  entirely  checked  could  spontaneously 
lapse  into  an  inflammatory  state  at  so  long  a  period  after  an  apparent 
cure.  It  is  possible  that  patients  with  sexual  difficulties  are  no  more 
deceitful  than  those  who  present  themselves  for  the  cure  of  other 
affections,  but  such  is  not  the  impression  that  the  surgeon  is  likely 
to  derive  by  observation  of  such  cases.  It  might  be  supposed  that 
the  average  individual  has  sufficient  respect  for  his  own  physical 
interests  to  be  perfectly  frank  and  honest  with  his  physician,  and  it 
has  been  aptly  said  that  "the  man  who  deceives  his  doctor  is  a  fool." 
But,  as  far  as  his  experience  goes,  the  writer  is  inclined  to  believe 
that,  if  this  proposition  be  true,  imbecility  is  largely  prevalent  in  our 
community.  Whether  the  moral  turpitude  of  the  venereal  patient  is 
due  to  a  sense  of  shame,  akin  to  that  which  impels  him  to  apply  the 
water-closet  theory  to  the  origin  of  his  disease  when  he  is  well  aware 
of  its  true  origin,  or  to  a  desire  to  lessen  his  financial  responsibility 
to  his  surgeon,  is  a  question  that  it  would  be  difficult  to  answer.  To 
say  the  least,  it  is  safe  to  assume  that  there  is  no  class  of  patients 
so  aggravating  as  those  met  with  in  genito-urinary  practice. 

Treatment  of  the  Complications  of  Urethritis. 

It  is  necessary  to  say  a  few  words  regarding  the  special  treatment 
of  the  complications  of  urethritis. 

Severe  Chordee  akd  Urethral  Hemorrhage. 

This  is  best  controlled  by  the  administration  of  the  anaphrodisiac 
remedies  already  recommended  and  the  application  of  the  cold-water 


TREATMENT   OF  THE   COMPLICATIONS   OF  URETHRITIS.  493 

coil  or  balloon-rubber  ice-bag.  The  danger  of  hemorrliage  is  lessened 
by  the  proper  management  of  the  chordee.  When  severe  bleeding 
does  occur  as  a  consequence  of  rupture  of  the  corpus  spongiosum 
from  forcible  straightening  of  the  penis,  it  may  be  controlled  in  most 
instances  by  the  cold-water  coil.  If  this  is  unsuccessful,  a  gum 
catheter  may  be  passed  into  the  urethra  beyond  the  i3oint  of  rupture, 
and  the  cold-water  coil  wrapped  tightly  around  the  penis ;  the  injec- 
tion of  astringents  into  the  canal  might  possibly  become  necessa.ry  if 
the  hemorrhage  proved  obstinate.  The  oil  of  turpentine  internally 
is  often  of  the  greatest  service  in  urethral  hemorrhage. 

Folliculitis  and  Peri-Urethral  Phlegmon. 

These  conditions  are  best  treated  upon  conservative  principles  in 
the  majority  of  cases.  As  soon  as  either  of  these  complications 
manifests  itself,  injections  and  all  stimulating  methods  of"  treatment 
should  be  stopped,  and,  if  j)ossible,  the  patient  should  be  kept  per- 
fectly quiet.  Hot  applications  will  usually  bring  about  resolution  of 
the  swelling  after  a  time.  Some  cases  are  very  stubborn,  but,  as  a 
rule,  the  little  tumors  characteristic  of  folliculitis  become  absorbed ; 
sometimes,  however,  they  remain  as  small  circumscribed  indurations, 
and  appear  to  keep  up  irritation.  Under  such  circumstances  they 
may  be  excised.  Excision  is  recommended  by  some  authorities  as  a 
routine  practice,  under  the  supposition  that  the  tumors  inevitably  sup- 
purate, and  that  there  is  great  danger  of  rupture  into  the  urethra, 
followed  by  extravasation  of  urine,  etc.  The  author  thinks,  however, 
that,  as  a  rule,  when  the  inflammation  of  the  urethra  subsides  to  such 
an  extent  that  the  duct  of  the  follicle  becomes  patent,  the  little  tumor 
discharges  its  contents  into  the  canal  and  the  wall  of  the  follicle 
eventually  shrinks  down  to  its  normal  size ;  this  discharge  of  its  con- 
tents being  usually  evidenced  by  a  sudden  increase  in  the  urethral  dis- 
charge. The  follicles  may  refill  and  again  discharge  an  indefinite 
number  of  times  and  cause  a  succession  of  re-infections  of  the  canal. 
Should  the  swelling  be  marked  or  painful,  or  if  fluctuation  be  evi- 
dent in  peri-urethral  phlegmon,  an  incision  must  be  made  at  once ; 
this  has  not  been  necessary,  however,  in  quite  a  number  of  cases 
which  the  author  has  seen.  Conservatism,  it  is  true,  may  be  carried 
t(jo  far,  l3ut  it  is  presumed  that  the  intelligent  surgeon  will  know 
when  to  cut,  there  being  perhaps  more  danger  in  delay  than  in  early 
incision. 

Conservatism  is  not  so  applicable  in  case  of  peri-urethral  phlegmon 
in  the  perineal  portion  of  the  urethra  as  in  cases  the  involving  the 
pendulous  ])f)rtion  of  tlie  canal.     When  the  perineum  becomes  hard 


494  LYDSTON— DISEASES  OF  THE  MALE  URETHEA. 

and  brawny,  it  is  best  to  make  an  early  incision,  tlie  operation  being 
in  itself  harmless.  If  in  such  instances  an  abscess  has  formed  and 
opened  into  the  urethra  before  the  patient  has  come  under  observa- 
tion, the  case  should  be  carefully  watched  and  free  incisions  made. 
If  at  any  time  a  marked  increase  in  the  perineal  swelling,  chills, 
hectic  and  general  constitutional  disturbance  should  occur,  as  evi- 
dences of  new  purulent  foci  or  urinary  infiltration,  or  if  the  swelling 
in  the  perineum  is  extensive  and  there  is  a  disposition  to  pointing  of 
matter  at  any  particular  spot,  external  perineal  section  is  required. 
In  such  cases  a  fistula  results  that  is  likely  to  heal  spontaneously, 
but  may  require  surgical  attention  later  on. 

Retention  op  Urine. 

The  conditions  producing  the  retention  are  to  be  considered  care- 
fully in  deciding  upon  its  treatment.  In  a  given  case  occurring  in 
the  course  of  a  gonorrhoea,  we  must  remember  that  the  factors  in  its 
production  are  several,  viz.,  (1)  inflammatory  swelling  of  the  mucous 
membrane  and  consequent  diminution  of  the  calibre  of  the  urethral 
tube;  (2)  irritation  produced  by  the  acid  urine;  (3)  prostatic  con- 
gestion; (4)  muscular  spasm.  In  patients  who  have  suffered  from 
previous  attacks  there  may  be  a  stricture,  to  which  the  foregoing 
factors  are  superadded  as  plus  conditions.  A  prostatic  abscess  may 
be  present,  causing  retention  by  simple  pressure ;  this  is  immediately 
relievable  by  incision. 

The  indications  for  treatment  are  plain:  sedatives,  derivatives, 
antispasmodics,  alkaline  diluents,  and  rest  comprising  the  main 
features. 

A  full  dose  of  morphine  hypodermically  or  per  rectum,  and  a 
hot  sitz-bath,  to  be  repeated  as  occasion  demands,  are  of  immediate 
necessity.  Ice  in  the  rectum  sometimes  assists  in  relieving  local 
congestion.  Leeches  to  the  perineum  and  anus  are  often  very  valu- 
able. Hot  drinks  of  demulcent  infusions  are  of  service  as  adjuvants. 
If  abscess  exists  about  the  prostate,  an  incision  is  necessary. 

An  injection  of  cocainized  oil  into  the  urethra  may  be  of  service. 
The  dread  of  painful  micturition  and  the  reflex  effect  of  the  irritating 
urine  is  often  an  important  factor  in  the  etiology  of  retention;  the 
cocaine  may  relieve  this.  The  catheter  should  be  used  only  as  a 
last  resort.  It  is  far  better,  in  the  author's  opinion,  to  tap  above  the 
pubes  than  to  use  the  catheter,  other  things  being  equal.  If  for  any 
reason  it  is  decided  to  use  the  catheter,  an  anaesthetic  should  gener- 
ally be  given ;  cocaine,  however,  may  be  used.  The  greatest  gentle- 
ness should  be  exhibited  in  the  passage  of  the  instrument.     Before 


TREATMENT  OF  THE   COMPLICATIONS   OF  URETHRITIS.  495 

passing  it,  the  uretlira  should  be  thoroughly  and  deeply  flushed  with 
a  mild,  warm  antiseptic  solution.  By  these  means  we  may  be  able 
to  avoid  infecting  the  deep  urethra  and  bladder.  In  the  author's 
experience,  instrumental  interference  has  rarely  been  necessary. 

Prostatitis. 

The  treatment  of  prostatitis  is  considered  in  the  article  on  Dis- 
eases of  the  Prostate. 

COWPERITIS. 

Cowperitis  requires  rest,  the  application  of  leeches,  and  the  pro- 
longed use  of  hot  applications.  Should  the  perineum  become  tense 
and  brawny,  or  should  there  be  severe  pain  or  retention  of  urine,  an 
incision  must  be  made  into  the  swelling  without  waiting  for  the 
formation  of  pus.  If  at  the  end  of  a  week  or  ten  days  improvement 
does  not  occur,  an  incision  is  warrantable  in  any  case.  It  will  be 
found,  however,  that  in  many  instances  the  inflammatory  process 
will  resolve  without  the  formation  of  pus,  particularly  if  the  cellular 
tissue  of  the  perineum  is  not  extensively  involved.  Cowperitis  is  not 
always  the  result  of  gonorrhoea.  The  author  has  seen  a  typical  case 
of  the  disease  in  a  tuberculous  patient,  who  had  no  urethral  difiiculty. 
In  this  instance  the  trouble  appeared  to  be  due  to  a  violent  strain, 
and  was  probably  not  of  a  true  tubercular  nature,  inasmuch  as  the 
cavity  healed  speedily  and  perfectly  after  incision,  and  no  other  foci 
of  infection  appeared.  Even  if  allowed  to  break  spontaneously,  the 
pus  in  cowperitis  usually  appears  externally.  It  may,  however,  open 
into  the  urethra  and  result  in  the  formation  of  fistula  or  infiltration 
of  urine,  abscess,  and  sloughing. 

Acute  Cystitis. 

The  indications  for  treatment  in  this  complication  of  urethritis 
are  simple  and  exceedingly  plain.  Kest,  a  milk  diet,  anodynes 
per  rectum,  per  os,  or  hypodermically,  hot  sitz-baths,  hot  rectal 
irrigation,  saline  laxatives, — with  or  without  mercurials, — alkaline 
diluents,  plenty  of  liure  water,  and  demulcent  drinks  comprise  the 
principal  therapeutic  resources  in  this  disease.  Hot  fomentations, 
turpentine  stupes,  or  poultices  over  the  hypogastrium  are  often 
serviceable  in  general  cystitis. 

The  list  of  drugs  for  internal  administration  comprises  such  prep- 
arations as  piclii,  kava-kava,  uva  ursi,  cubebs,  sandalwood  oil,  pa- 
reira  brava,  triticum  repens,  linseed,  and  slippery  elm.  Some  of 
these  medicaments  are  available  only  in  the  form  of  infusion,  others 


496  LYDSTON — DISEASES  OF  THE  MALE  URETHEA. 

in  that  of  fluid  extracts.  Acetate  of  potassium,  citrate  of  potassium, 
benzoate  of  sodium,  liquor  potassse,  salol,  boracic  acid  and  salicylate 
of  sodium  are  all  serviceable  drugs  for  their  antacid,  antiseptic,  and 
soothing  effect  upon  the  inflamed  mucous  membrane. 

Epididymitis  and  Oechitis. 

The  most  important  indication  in  the  treatment  of  acute  inflamma- 
tion of  the  testis  is  to  put  the  patient  absolutely  at  rest.  All  stimu- 
lation of  the  urethra  by  balsams,  injections,  and  irrigations  should 
cease.  In  some  instances,  however,  the  balsams  may  be  given  if 
they  are  found  to  be  soothing  to  the  inflamed  membrane.  Hot  sitz- 
baths,  twice  or  thrice  daily,  should  be  prescribed.  An  absolute  milk 
or  other  unstimulating  diet  should  be  adhered  to.  Alkalies  in- 
ternally are  always  in  order.  The  author  has  found  salicylate  of 
sodium  to  be  of  especial  advantage  in  some  of  these  cases ;  where  the 
pain,  fever,  and  nervous  disturbance  are  marked,  phenacetin  or  the 
bromides  may  be  combined  Avith  the  salicylate.  It  has  occurred 
to  the  author  that  underlying  many  of  these  cases  of  acute  inflamma- 
tion of  the  testis  a  rheumatic  or  gouty  diathesis  exists  as  a  predispos- 
ing cause.  Under  such  circumstances  the  action  of  the  salicylic  acid 
can  be  very  readily  explained.  Whether  this  supposition  be  correct 
or  not,  free  salicyKc  acid  and  its  compounds  will  often  be  found  to 
be  extremely  efficacious.  Pulsatilla  is  occasionallj^  beneficial,  but  its 
range  of  application  is  apparently  more  limited  than  its  enthusi- 
astic advocates  seem  to  believe.  The  suggestion  originally  made  by 
Dr.  Piffard  to  give  the  drug  in  almost  homoeopathic  doses  seems  to 
be  unsound.  After  considerable  experimenting,  the  author  has  con- 
cluded that  while  the  drug  is  more  or  less  efficacious,  it  must  be 
given  in  doses  sufficiently  large  to  secure  a  certain  degree  of 
physiological  effect.  Gelsemium  in  combination  with  the  bromides 
has  appeared  to  be  of  special  advantage  in  allaying  irritability  of  the 
affected  structure.  Mercurial  and  saline  cathartics  are  always  in- 
dicated. Opium  should  be  administered,  if  necessary,  to  control  pain. 
The  local  measures  of  treatment  are  by  far  the  most  important. 

Narcotizing  the  testis  by  means  of  tobacco  and  linseed-meal 
poultices,  originally  recommended  by  the  late  Dr.  William  H.  Van 
Buren,  constitutes  the  most  efficacious  local  application  that  can  be 
made.  When  the  inflammation  is  very  acute  and  the  pain  severe, 
four  or  five  leeches  applied  to  the  scrotum  will  be  found  to  be  of 
incalculable  benefit  as  a  preliminary  to  other  local  measures  of  treat- 
ment. The  testis  should  be  supported  by  a  pillow  or  roll  of  gauze 
between  the  thighs  so  as  to  avoid  the  injurious  influence  of  gravity. 


TREATMENT  OF  THE   COMPLICATIONS  OF  URETHRITIS.  497 

Scarification  of  the  scrotal  veins,  the  bleeding  being  subsequently 
encouraged  by  warm  fomentations,  is  very  often  beneficial.  When  the 
pain  is  severe,  and  marked  acute  hydrocele  exists,  Vidal's  method  of 
subcutaneous  puncture  of  the  tunica  vaginalis  sometimes  relieves  the 
symptoms  almost  magically.  It  has  been  the  author's  experience, 
moreover,  that  cases  treated  in  this  manner  terminate  much  more 
rapidly  than  those  in  which  less  radical  measures  have  been  insti- 
tuted. In  case  the  testis  proper  is  primarily  or  markedly  involved, 
the  question  of  subcutaneous  incision  of  the  tunica  albuginea  for  the 
purpose  of  relieving  tension  must  receive  due  consideration.  Where 
it  is  inconvenient  to  apply  poultices,  the  author  has  found  the  appli- 
cation of  the  following  narcotic  and  sedative  ointment  to  be  very 
efficient : 

ij    Menthol gr.  xl. 

Ext.  belladonnse gr.  xx. 

Ext.  aconiti gr.  x. 

Lanolin. q.s.  ad  §  ij. 

M.     Sig.  :  To  be  spread  on  lint  and  continuously  applied  to  the  testicle. 

It  may  be  changed  two  or  three  times  in  the  course  of  twenty-four 
hours.  As  soon  as  the  tenderness  in  the  testis  has  sufficiently  sub- 
sided, strapping  the  affected  organ  may  be  advisable.  Great  care  is 
necessary  in  determining  the  precise  period  at  which  it  is  safe  to 
begin  strapping  the  organ,  as  gangrene  of  the  testis  has  been  known 
to  occur  from  premature  or  careless  strapping.  It  is  advisable  not  to 
employ  this  method  of  treatment  unless  the  patient  is  so  situated  as 
to  be  readily  accessible  to  the  surgeon. 

The  internal  use  of  mercury  and  the  iodides  and  the  local  appli- 
cation of  the  faradic  current  are  of  great  value  in  procuring  resolu- 
tion where  the  inflammation  shows  a  tendency  to  become  chronic. 
It  is  the  author's  opinion  that  counter-irritation,  electricity,  and 
alteratives  should  be  employed  in  practically  every  case  after  the 
subsidence  of  the  acute  symptoms,  for  the  purpose  of  preventing  as 
far  as  possible  permanent  induration  and  occlusion  of  the  epididymal 
tube. 

GONORRHCEAL  EhEUMATISM.     ~ 

The  treatment  of  this  complication  is  not  especially  satisfac- 
tory, being  of  a  x^alliative  rather  than  a  curative  character.  The 
treatment  for  the  uretliritis  should  usually  be  persisted  in,  for,  as 
a  rule,  the  sooner  the  local  condition  improves,  the  sooner  the 
rheumatic  complication  will  yield.  If,  however,  the  discharge  has 
ceased,  it  is  best  to  let  the  urethra  severely  alone.  When  patients 
Voh.  I.— 33 


498  LYDSTON — DISEASES   OF  THE  MALE   URETHRA. 

are  debilitated,  tonics,  sucli  as  stryclmine,  quinine,  iron,  ar- 
senic, and  cod-liver  oil  are  of  advantage.  The  skin  and  bowels 
should  be  kept  active  and  elimination  favored  by  the  use  of  pilo- 
carpine hypodermically.  Pain  should  be  relieved  by  the  use  of 
opiates ;  hot  applications  and  fixation  of  the  inflamed  joint  are  es- 
sential for  the  same  purpose.  Should  the  knee  be  involved,  Buck's 
extension  apparatus  should  be  applied  as  in  ordinary  forms  of 
arthritis.  The  application  of  fifteen  or  twentj^  leeches  to  the  joint  will 
often  prove  serviceable.  Flannels  wrung  out  of  hot  water  and  sprinkled 
with  turpentine  form  a  useful  application  to  the  inflamed  joint.  As 
the  inflammation  subsides,  blisters  or  iodine  wiU  be  found  to  promote 
resolution.  Mercury  and  iodide  of  potassium  internally  are  of  great 
service  in  the  chronic  stage  of  the  disease.  The  author  has  had  ex- 
cellent results  from  intra-articular  injections  of  iodoform  emulsion. 
It  is  well  in  all  cases  to  try  the  effect  of  the  salicylates,  inasmuch  as 
the  rheumatic  or  gouty  diathesis  may  exist  as  a  predisposing  cause 
of  the  disease.  The  more  important  joints,  such  as  the  knee,  are 
best  treated  by  the  plaster-of-paris  bandage  as  soon  as  the  acute 
inflammation  has  subsided.  Passive  movement,  and  perhaps  meas- 
ures to  break  up  ankylosis,  are  required  in  the  later  stages  of  the 
affection.  Turkish  and  electric  baths,  static  electricity,  friction  and 
massage  are  serviceable  adjuvants.  Static  electricity  is  particularly 
beneficial.  The  author  has  been  much  impressed  with  the  value  of 
this  remedy  in  neglected  cases  of  chronic  enlargement  of  the  joints. 
During  the  acute  stage  of  gonorrhoeal  rheumatism  a  milk  diet  is  very 
essential. 

The  ocidar  complications  of  gonorrhoea  belong  to  the  province  of 
ophthalmology,  and  their  treatment  does  not  concern  us  here. 

Bubo. 

The  slighter  forms  are  curable  by  limiting  movement  and  the  ap- 
plication of  iodine.  In  the  more  marked  forms  the  patient  should 
take  to  bed  and  apply  hot  linseed-meal  poultices,  sprinkled  with 
laudanum,  every  two  hours.  The  hot  poultice  is  the  best  pus 
prophylactic  at  our  command.  Should  resolution  not  occur  promptly, 
extirpation  of  the  enlarged  glands  is  indicated.  If  we  operate 
aseptically,  before  peri-adenitis  and  infection  of  the  surrounding 
tissues  have  occurred,  and  close  the  wound  accurately,  healing  is  quite 
prompt.  This  may  seem  radical,  but  the  author  has  become  thorough- 
ly disgusted  with  the  tiresome  method  of  waiting  for  a  bubo  to 
suppurate,  and  then  waiting  for  weeks  or  months  for  it  to  heal.  If 
prompt  healing  does  not  follow  a  radical  operation,  the  part  is  still 


STRICTURE   OF  THE   URETHRA.  499 

in  much  better  shape  for  subsequent  granulation  and  cicatrization 
than  if  a  distinct  abscess  be  allowed  to  form. 


Balanitis  and  Vegetations. 

Circumcision  will  prevent  balanitis  in  cases  of  redundant  and 
phimosed  prepuce.  In  default  of  circumcision,  absolute  cleanliness 
may  prevent  balano-posthitis.  When  this  complication  comes  on, 
the  indications  are  to  keep  the  parts  clean  and  dry.  Astringent  and 
antiseptic  lotions  and  absorbent  powders  are  useful.  The  iodide, 
sulphate,  or  acetate  of  zinc,  alum,  bichloride  of  mercury,  permangan- 
ate of  potassium  and  many  other  drugs  are  serviceable  in  mild  solu- 
tions. Finely  triturated  bismuth,  calomel,  lycopodium,  oxide  of 
zinc,  and  oleate  of  zinc  are  valuable.  The  last-named  drug  is 
perhaps  the  best  of  all,  if  a  good  preparation  be  used.  The  stearate 
of  zinc  is  another  elegant  preparation.  Severe  balanitis  may  require 
a  dorsal  incision  of  the  prepuce  to  expose  the  parts  for  inspection  and 
treatment. 

Vegetations  should  be  cut  away  with  the  scissors  and  their  bases 
cauterized  with  fuming  nitric  acid.  Cleanliness,  dryness,  and  per- 
haps circumcision,  are  necessary  to  avoid  their  recurrence.  The 
same  principles  of  treatment  should  govern  here  as  in  balanitis. 

STRICTURE   OF   THE  URETHRA. 

Stricture  of  the  male  urethra  is  by  far  the  most  important  of  all 
the  surgical  diseases  of  the  genito-urinary  apparatus.  It  is  of  im- 
portance not  only  because  of  its  extreme  frequency,  the  special  condi- 
tion which  most  often  gives  rise  to  it  affecting  sooner  or  later  a  large 
proportion  of  male  humanity,  but  because  of  its  important  relations 
to  secondary  pathological  conditions  of  organs  more  vital  than  the 
structure  primarily  affected. 

Stricture  of  the  urethra  may  be  defined  as  an  abnormal  diminu- 
tion of  the  lumen  of  the  canal  at  one  or  more  points  or  throughout 
its  entire  course,  due  to  any  cause  whatsoever,  whether  temporary 
or  permanent.     It  may  arise  from  any  of  the  following  conditions : 

1.  Pressure  from  without,  due  to  (a)  neoplastic  formations; 
(6)  extravasations  of  blood  or  urine  from  injury ;  (c)  purulent  collec- 
tions and  infiltration ;   (d)  fracture  of  the  pelvic  bones. 

2.  Spasm  of  the  muscles  in  and  about  the  urethra,  due  to  (a)  direct 
irritation  by  lesions  of  the  canal;  (b)  direct  or  reflex  irritation  from 
foreign  bodies  in  the  canal ;  (c)  reflex  irritation  from  more  or  less 
remote  pathological  conditions ;   (d)  the  introduction  of  instruments ; 


500  LYDSTON — DISEASES   OF  THE  MALE   UKETHRA. 

(e)  emotional  excitement;   (/)  malaria  (?) ;   (g)  Mghly  acid  and  con- 
centrated urine,  and  occasionally  oxaluria  and  gravel. 

3.  Congestive  or  inflammatory  engorgement  of  tlie  urethra,  due 
to  (a)  acute  urethritis ;  (b)  traumatism  of  the  urethra ;  (c)  inflamma- 
tion in  and  about  organic  obstructions. 

4.  Thickening  of  the  urethral  walls,  clue  to  (a)  congestive  and 
granular  patches  in  the  mucous  membrane,  i.e.,  superficial  infiltra- 
tion from  chronic  inflammation ;  (b)  ijlastic  infiltration  and  formation 
of  connective  tissue  in  the  meshes  of  the  corpus  spongiosum  from 
severe  and  long-continued  inflammation ;  (c)  cicatricial  deposit  in  the 
corpus  spongiosum  and  urethral  walls  incidental  to  traumatism ;  (d) 
cicatricial  deposit  due  to  the  action  of  various  caustics  and  powerful 
irritants;  (e)  cicatricial  deposit  following  ulceration  or  sloughing 
produced  by  the  impaction  of  foreign  bodies. 

5.  Deficient  elasticity  of  the  urethral  walls  and  corpus  spongio- 
sum :  (a)  From  congenital  sparsity  of  elastic  and  muscular  fibre  and 
a  preponderance  of  fibro-connective  tissue ;   (b)  from  inflammation. 

6.  Congenital  narrowing  of  the  urethra,  or  slight  atresia  from  de- 
fective foetal  development. 

7.  Polypi  of  the  urethral  mucous  membrane. 

Varieties. 

From  a  clinical  standpoint,  strictures  may  be  divided  according  to 
their  origin  into:  (1)  Spasmodic;  (2)  congestive  or  inflammatory 
(circumscribed  or  general) ;  (3)  organic  or  fibrous  (permanent),  i.e., 
neoplastic. 

Those  varieties  of  stricture,  the  nomenclature  of  which  depends 
upon  real  or  supposed  difi'erences  in  the  condition  producing  the  ob- 
struction, are  not  always  to  be  differentiated  clinically  because  of  the 
fact  that  the  several  conditions  may  coexist  in  varying  proportions 
in  any  given  case  of  the  disease.  Thus  inflammatory  or  congestive 
narrowing  of  the  urethra,  although  sufficient  per  se  to  produce  ob- 
struction in  some  cases,  is  nearly  always  complicated  by  spasmodic 
narrowing  of  the  canal.  Simple  spasmodic  stricture  is  relatively 
rare,  occurring  only  as  a  result  of  reflex  irritation,  of  mental  impres- 
sions, or  of  instrumentation  when  the  urethra  is  very  sensitive.  On 
the  other  hand,  spasmodic  stricture  dependent  upon  acute  or  chronic 
organic  changes  in  the  urethral  mucous  membrane  is  very  frequent. 
Again,  there  are  few  cases  of  organic  stricture  that  are  not  com- 
plicated at  one  time  or  another  by  inflammation,  congestion,  or 
muscular  spasm ;  in  fact,  all  of  these  elements,  which  the  author  would 
term  plus  conditions,  and  particularly  spasm,  are  apt  to  require  at- 
tention at  various  times  during  the  treatment  of  organic  stricture. 


SPASMODIC   STRICTUEE.  501 

Spasmodic  Stricture. 

Spasmodic  stricture — or,  as  it  may  justly  be  called,  pseudo-stric- 
ture— may  be  defined  as  a  diminution  of  the  calibre  of  the  urethra, 
due  to  spasmodic  contraction  of  the  muscular  fibres  in  and  about  the 
walls  of  the  canal.  This  contraction  may  produce  complete  retention 
as  a  result  of  such  exciting  causes  as  acid  urine,  intemperance,  or 
sexual  indulgence. 

Spasmodic  stricture  is  merely  an  intensification  of  the  physio- 
logical function  of  the  cut-off,  accelerator  urinse,  and  compressor  ure- 
thrse  muscles,  in  which,  from  various  sources  of  irritation,  the  muscu- 
lar fibres  are  spasmodically  contracted  and  the  volitional  power  of 
the  patient  over  the  act  of  urination  is  for  the  time  being  held  in 
abeyance. 

The  site  of  spasmodic  stricture  varies.  There  are  almost  always 
two  points  of  spasmodic  contraction :  (a)  At  the  point  of  irritation, 
and  (6)  in  the  musculo-membranous  urethra. 

1.  When  a  foreign  body  is  introduced  into  the  canal,  the  urethra 
resents  the  liberty  at  any  point  of  irritation,  and  there  occurs  simul- 
taneously with  a  slight  contraction  at  the  point  irritated,  a  reflex 
spasm  of  the  cut-off  and  urethral  muscles.  The  same  is  often  true  in 
cases  of  organic  stricture  in  the  penile  portion  of  the  urethra  or  at 
the  meatus.  This  is  an  important  practical  point,  for  it  has  been 
established  that,  simultaneously  with  the  removal  of  an  anterior 
point  of  obstruction  and  irritation,  a  supposed  deep  organic  stricture 
often  disappears. 

2.  The  entire  canal  may  be  spasmodically -contracted  and  resent 
the  introduction  and  withdrawal  of  instruments. 

3.  The  musculo-membranous  region  may  alone  be  involved.  This 
happens  in  cases  in  which  an  organic  lesion  exists  in  the  deep  ure- 
thra and  in  those  in  which  spasm  is  due  to  reflex  causes. 

The  causes  of  spasmodic  stricture  may  be  classified  as : 
1,  Predisjjosing  Causes. — (a)  General  hyperaesthesia ;  (b)  local 
hypersesthesia.  Both  of  these  causes  are  modified  by  a  nervous 
temperament,  debilitated  and  cachectic  states  of  the  system,  the 
rheumatic  and  gouty  diatheses,  intemperance,  high  living,  faulty 
sexual  hygiene,  etc.  (c)  Acute  or  chronic  disease  of  the  urinary 
organs.  This  is  the  most  frequent  predisposing  cause,  and  it  is 
rarely  indeed  that  a  case  of  spasmodic  stricture  is  met  with  in  which 
a  more  or  less  damaged  state  of  the  canal  does  not  exist.  So  uni- 
formly is  it  present,  that  it  is  always  to  be  suspected  until  organic 
disease  has  been  excluded  by  exi)loration.  Congested  and  fungating 
patches,  erosions  of  the  mucous  membrane,  acute  and  chronic  urethri- 


502  LTDSTON — DISEASES   OF  THE   MALE  URETHRA. 

tis,  and  organic  stricture  of  whatever  degree,  constantly  predispose  to 
spasmodic  contraction,  botli  at  tlie  point  of  irritation  and  at  the  cut 
off  muscle ;  such  predisposing  causes  are  always  effective  in  its  pro- 
duction during  the  passage  of  an  instrument.  A  congenital  narrow- 
ing of  the  meatus  or  other  parts  of  the  canal  may  give  rise  to  reflex 
spasm  of  the  deep  urethral  muscles  in  any  case  in  which  an  instru- 
ment is  passed,  of  a  sufficient  size  to  produce  stretching  of  the  sensi- 
tive tissues  at  the  point  of  contraction.  As  ah^eady  noted,  when  in- 
struments are  introduced  under  the  pathological  conditions  alluded 
to,  there  is  a  spasm  at  the  site  of  the  lesion  and  another  deep  down 
in  the  canal. 

2.  Exciting  Causes. — 1,  Passage  of  instruments;  2,  sexual  excite- 
ment or  excess;  3,  injury  to  the  canal — chemical  or  traumatic;  4, 
a  debauch;  5,  cold-taking;  6,  foreign  bodies;  7,  drugs,  such  as  can- 
tharides  and  turpentine;  8,  reflex  irritation;  9,  malaria  (?) ;  10,  men- 
tal emotions. 

A  survey  of  the  various  exciting  causes  of  spasmodic  stricture  is 
sufficient  to  indicate  the  fact  that  in  nearly  all  instances  the  element 
of  spasm  is  associated  with  congestion  and  inflammation — conditions 
which  such  special  causes  are  most  apt  to  excite.  Spasm  due  to 
drugs  is  usually  associated  with  considerable  inflammation  and  at- 
tended by  frequent  and  painful  micturition  (strangury),  perhaps 
associated  with  urethral  hemorrhage.  The  most  frequent  exciting 
causes  are  intemperance,  exjjosure  to  cold  and  wet,  and  sexual  excess. 
Highly  acid  urine  in  gouty  patients  is  said  to  act  as  an  exciting  cause 
per  se  in  some  cases,  but  it  is  in  the  highest  degree  doubtful  if  such 
a  condition  of  the  urine  could  bring  about  obstructive  spasm  in  a 
perfectly  healthy  canal.  It  is,  however,  an  important  element  in 
spasm  produced  by  excesses  of  various  kinds  and  cold-taking.  In- 
strumentation of  a  sensitive  canal,  especially  if  organic  disease 
exists,  is  likely  to  develop  spasmodic  stricture  which  may  last  for 
some  days  or  weeks. 

It  was  shown  some  years  ago  by  Dr.  Fessenden  Otis  that  spas- 
modic stricture  frequently  becomes  chronic.  This  condition  of 
chronic  spasm  he  termed  urethrismus.  It  is  usually  due,  according 
to  Otis,  to  sources  of  reflex  irritation  in  the  urethra,  or  in  the  vicinity 
of  the  scrotum  and  testicles.  It  may,  however,  be  due  to  highly  acid 
urine  and  is  an  occasional  concomitant  of  the  gouty  diathesis. 

Diagnosis. 

The  diagnosis  of  spasmodic  stricture  is  usually  comparatively 
simple,  particularly  in  those  cases  in  which  retention  comes  on  sud- 


SPASMODIC   StEICTUEE.  503 

denly.  It  is  obvious  that  tlie  sudden  occurrence  of  retention  in  a  case 
of  organic  stricture,  or  other  obstructive  lesion  of  the  genito-urinary 
tract,  in  which  the  stream  of  urine  has  been  previously  only  moder- 
ately lessened  in  size,  must  depend  upon  some  complicating  condi- 
tion— either  inflammation  and  congestion  at  the  site  of  the  organic 
lesion,  spasmodic  contraction  of  the  cut-off  muscle,  or  both  condi- 
tions in  combination.  A  certain  degree  of  inflammation  or  conges- 
tion is  to  be  inferred  in  every  case  of  spasmodic  retention  of  urine 
and  requires  due  consideration ;  the  predominating  element  of  spasm 
is,  however,  the  principal  feature. 

As  a  rule,  in  cases  of  sudden  retention  of  this  kind  there  is  a 
history  of  some  one  or  more  of  the  exciting  causes  which  have  been 
enumerated. 

In  determining  the  dependence  of  retention  of  urine  upon  spasm, 
it  is  necessary  to  remember  that  in  by  far  the  majority  of  cases  there 
is  some  organic  foundation  for  the  condition.  When,  in  the  course  of 
treatment  for  organic  stricture  of  small  calibre,  retention  suddenly 
occurs,  the  predominating  condition  is  usually  congestion  or  inflam- 
mation. The  occurrence  of  acute  urethritis  during  the  course  of 
marked  organic  stricture  is  apt  to  superinduce  sudden  retention. 
The  condition  in  these  cases — although  a  spasmodic  element  exists — 
is  mainly  congestion  and  inflammation  at  the  site  of  the  stricture, 
which  produces  sufflcient  swelling  to  completely  close  it  for  the  time 
being.  Urethritis  produced  by  the  introduction  of  instruments 
brings  about  retention  in  the  same  way.  Cases  of  stricture  of  large 
calibre,  in  which  there  is  little  or  no  obstruction  to  the  passage  of 
urine,  may  suddenly  develop  retention  from  spasm.  It  is  doubtful 
whether  congestion  or  inflammation  alone  could  produce  closure  of 
the  canal  in  such  cases. 

It  is  sometimes  difficult  to  determine,  during  instrumentation  of 
the  canal,  how  much  of  the  obstruction  to  the  passage  of  instiniments 
is  due  to  organic  contraction,  and  how  much  to  spasm.  For  exam- 
ple, after  an  instrument  has  passed  a  stricture  of  large  calibre  in  the 
penile  portion  of  the  urethra,  or  an  inflamed  and  irritable  meatus,  it 
will  be  found  to  be  obstructed  in  many  cases  as  it  enters  the  mem- 
branous region.  A  steel  instrument  is  less  likely  to  be  obstructed 
than  a  soft  bulbous  one,  and  the  spasm  is  more  likely  to  yield  to 
steady  and  gentle  pressure  against  it  with  the  point  of  the  sound 
than  to  a  soft  bulb.  If  there  be  organic  contraction  in  slight  degree 
at  the  bulbo-membranous  junction,  a  steel  instrument  small  enough 
to  x^ass  the  stricture  in  the  anterior  portion  of  the  canal  will,  in  all 
probaljility,  slip  by  and  fail  to  detect  it.  A  large  bulbous  instrument 
will  usually  fail  to  i)ass  altogether,  but  if  a  small  bulbous  bougie  be 


504  LtDSTON — DISEASES   OF  THE  MALE  URETHRA. 

introduced,  it  will  be  found  that  tlie  spasm  of  the  surrounding  mus- 
cles, altliougli  insufficient  to  obstruct  the  passage  of  tlie  instrument 
into  tlie  bladder,  will  at  the  same  time  contract  tlie  stricture  in  such 
a  manner  that  the  shoulder  of  the  instrument  impinges  upon  it  as  it 
is  withdrawn.  The  peculiar  feel  imparted  to  the  bougie,  and  the 
sudden  snap  produced  by  the  passage  of  its  shoulder  through  the 
organic  contraction,  will  determine  the  exact  nature  of  the  case. 

There  are  some  exceptional  cases  of  chronic  spasmodic  stricture 
in  which  the  real  condition  can  be  demonstrated  only  by  the  subtrac- 
tion of  all  sources  of  direct  or  reflex  irritation,  after  which  the  sup- 
posed organic  stricture  will  disappear. 

Treatment. 

Obviously,  the  first  indication  in  the  treatment  of  spasmodic  stric- 
ture is  to  remove  all  predisposing  caiises  as  far  as  possible.  Such 
conditions  as  the  gouty  and  rheumatic  diatheses  require  correction. 
General  nervous  irritability  and  hypergesthesia  may  require  nervine 
tonics,  or  sedatives  and  anti-spasmodics,  or  both,  according  to  the 
special  indications  present.  The  principles  of  genito-urinary  and 
sexual  hygiene  should  be  thoroughl}^  impressed  upon  the  mind  of  the 
patient.  Once  succeed  in  disabusing  the  patient's  mind  of  the  falla- 
cious notion  that  his  penis  and  testes  constitute  the  axis  around 
which  his  earthly  existence  revolves,  and  the  treatment  of  the  case  is 
much  simplified.  Every  possible  source  qf  local  and  reflex  irritation 
must  be  removed.  This  necessarily  involves  in  the  majority  of  cases 
the  cure  of  organic  lesions  of  the  urethra.  The  urine  should  be  kept 
bland  and  non-irritating  by  dietetic  measures  and  the  administration 
of  alkaline  remedies.  Careful  stud}^  should  be  given  in  each  case  to 
the  degree  of  tolerance  of  the  urethra  for  instrumental  manijmlations. 
The  amount  of  irritability  of  the  urethra  and  the  degree  of  spasm 
excited  by  the  passage  of  instruments  is  a  fair  criterion  of  the  fre- 
quency with  which  they  should  be  introduced  in  the  treatment  of 
organic  stricture. 

When  retention  comes  on  as  a  consequence  of  spasmodic  stricture, 
an  attempt  should  be  made  to  relieve  the  condition  by  derivation 
— with  a  view  of  removing  possible  congestion — and  by  antispas- 
modics. The  passage  of  instruments  should  be  avoided  if  possible, 
as  tending  to  increase  irritation  and  spasm.  The  full  hot  bath,  and 
morphine  by  the  mouth  or  hypodermically,  should  be  depended 
upon  as  far  as  practicable.  Very  often  the  j)atient  will  succeed  in 
passing  urine  while  in  the  hot  bath,  which  is  both  derivative  and 
antispasmodic.     When  these  simpler  measures  fail,  a  small  soft  cathe- 


OEGANlC   STRICTUKE,  505 

ter  should  be  carefully  introduced,  while  the  patient  is  in  the  bath  if 
possible.  If  necessary,  chloroform  or  ether  may  be  given  to  the  ex- 
tent of  full  anaesthesia,  for  the  purpose  of  relaxing  the  spasm. 
Whenever  retention  comes  on  in  the  course  of  organic  stricture,  it 
must  be  remembered  that  the  accident  is  not  due  to  the  organic  con- 
traction j9er  se,  but  to  certain  plus  conditions,  '^'•e.,  spasm,  congestion, 
and  oedema  of  tissue  in  varying  proportions.  The  relief  of  the  re- 
tention depends  upon  the  subtraction  of  these  plus  conditions  from 
the  primary  obstructing  factor  of  organic  contraction.  The  treat- 
ment of  urethrismus  is  chiefly  operative.  After  all  sources  of  reflex 
irritation  have  been  removed  the  urethrismus  disappears. 

Congestive   or   Inflamniatory  Stricture. 

This  is  usually  a  complicating  condition  rather  than  a  pathological 
entity,  being  much  less  frequently  met  with  as  a  prime  factor  in  the 
case  than  spasm.  Even  the  rare  existence  of  congestive  and  inflam- 
matory stricture  as  an  essential  condition  is  denied  by  many  sur- 
geons, but  it  would  at  least  appear  to  be  the  main  feature  of  a  minor 
proportion  of  cases  of  urinary  obstruction,  with  or  without  retention. 
This  congestive  or  inflammatory  obstruction  may  occur — (1)  as  the 
result  of  occlusion  of  the  urethra  by  extensive  infiltration  of  the 
mucous  membrane,  peri-urethral  connective  tissue,  and  corpus  spon- 
giosum, in  severe  or  virulent  urethritis ;  (2)  at  the  site  of  an  injury 
to  the  mucous  membrane  produced  by  instrumental  or  accidental 
trauma  from  within  or  without  the  canal ;  (3)  as  a  consequence  of 
acute  and  virulent  urethritis  affecting  strictures  of  large  calibre  or 
congested  and  granular  patches  of  the  mucous  membrane. 

The  indications  for  treatment  are  the  same  as  in  spasmodic  stric- 
ture— which  is  usually  a  complicating  factor — with  the  exception  that 
in  cases  in  which  hypersemia  is  believed  to  be  the  predominating 
condition  the  application  of  leeches  to  the  perineum  is  advisable. 

Organic  Stricture. 

Organic,  permanent,  or  fibrous  stricture  is  that  form  in  which  the 
narrowing  of  the  urethral  calibre  is  due  to  an  aggregation  of  organic 
tissue  formation,  and  may  be  either  congenital  or  acquired.  It  is 
most  often  acquired,  and  is  most  frequently  met  with,  between  the 
ages  of  twenty -four  and  forty-five. 

Very  rarely  indeed  does  a  stricture  give  trouble  for  the  first  time 
after  the  age  of  forty.  It  may  occur  at  any  time  after  the  period  of 
puberty. 


506  ltdston — diseases  of  the  male  urethra. 

Traumatic  Stricture. 

Traumatic  organic  stricture  may  occur  at  any  age.  The  youngest 
case  which  has  come  under  the  author's  observation  was  in  a  boy 
of  thirteen. 

Traumatic  stricture  is  usually  located  at  the  triangular  ligament. 
It  is  at  this  point  that  the  urethra  is  likely  to  be  injured  by  blows  or 
falls.  A  fall  astride  a  hard  object  or  a  kick  in  the  perineum  is  the 
usual  cause.  The  bulbo-membranous  urethra  is  caught  between  the 
impinging  body  and  the  sharp,  knife-like  lower  border  of  the  sub- 
pubic ligament,  and  a  very  slight  degree  of  force  may  therefore  pro- 
duce permanent  injury.  It  does  not  require  a  very  great  degree  of 
violence  to  completely  sever  the  urethra  in  this  situation.  The  pen- 
dulous urethra,  on  the  other  hand,  is  rarely  involved  in  traumatic 
stricture  on  account  of  the  difficulty  with  which  it  can  be  caught  be- 
tween two  impinging  bodies. 

Traumatic  stricture  is  distinctly  cicatricial.  It  is  rarely  amena- 
ble to  dilatation,  and  usually  requires  a  perineal  section. 

Congenital  Stricture. 

The  congenital  form  of  stricture  is  rare,  if  we  exclude  narrowing 
of  the  meatus.  The  existence  of  congenital  stricture  bej^ond  a  point 
one-fourth  of  an  inch  from  the  meatus  is  denied  by  the  majority  of 
surgical  authorities.  If,  however,  we  take  into  consideration  the 
occasional  occurrence  of  congenital  atresia  of  a  part  or  the  whole  of 
the  urethra,  the  possible  occurrence  of  localized  congenital  narrowing 
of  the  canal  seems  logical.  I  have  seen  a  number  of  cases  of  linear 
stricture  of  the  pendulous  portion  of  the  canal  which  I  believe  to 
have  been  of  congenital  origin. 

Congenital  stricture  of  the  meatus  is  a  relative  affair,  inasmuch 
as  it  is  not  per  se  productive  of  discomfort,  in  by  far  the  majority  of 
cases.  An  individual  with  a  meatus  narrower  than  the  average  is 
not  likely  to  be  annoyed  thereby,  providing  he  never  contracts 
gonorrhoea. 

In  order  to  determine  the  condition  of  the  urethra,  or  to  treat 
organic  disease  of  the  mucous  membrane,  the  meatus  must  admit  in- 
struments of  a  size  corresponding  to  the  largest  mean  diameter  of 
the  canal. 

Whenever,  therefore,  there  exists  a  suspicion  of  urethral,  pros- 
tatic, or  bladder  disease  and  the  meatus  is  contracted,  it  should  be 
enlarged  by  incision  to  a  size  sufficient  to  admit  an  instrument  which 
will  thoroughly  distend  the  canal. 


ORGANIC  STEICTURE.  507 

In  by  no  means  exceptional  instances  a  contracted  meatus  of  con- 
genital origin  lias  been  known  to  induce  reflex  neurotic  disturbances 
in  very  mucli  the  same  manner  as  does  a  phimosed  prepuce  in  some 
cases.  Spasmodic  stricture,  irritability  of  the  bladder  with  fre- 
quent micturition,  and  perhaps  other  more  suspicious  symptoms  of 
stone  have  been  known  to  arise  from  this  cause. 

Oeganic  Steicture  op  Inflammatory  Origin. 

According  to  conformation,  organic  acquired  stricture  occurs  in 
three  principal  varieties.  (1)  The  first  and  simplest  form  is  known 
as  the  linear  stricture,  the  obstruction  corresponding  to  that  which 
would  be  produced  by  tying  a  narrow  cord  about  the  canal. 

(2)  The  second  variety  is  wider,  and  is  known  as  the  annular 
form,  the  condition  being  mechanically  similar  to  that  which  would 
result  from  tying  a  flat  band  or  piece  of  tape  about  the  canal. 

(3)  The  third  form — which  is  divided  by  some  authorities  into 
several  peculiar  sub- varieties — involves .  a  considerable  extent  of  the 
urethra  in  an  irregular  contraction,  and  is  known  as  tortuous  stric- 
ture. For  practical  purposes  these  three  varieties  are  sufficiently 
distinctive. 

As  regards  their  clinical  features,  strictures  may  be  described  as 
(a)  simple  and  readily  dilatable;  (6)  irritable,  involving  local  hy- 
persesthesia  and  hypersemia;  (c)  resilient  or  elastic ;  id)  recurrent. 
This  classification  necessarily  depends  largely  upon  the  behavior  of 
the  stricture  under  treatment. 

The  number  of  strictures  is  variable.  It  has  most  generally  been 
accepted  that  stricture  is  usually  single,  but  it  will  be  found  in  by 
far  the  larger  number  of  cases,  if  the  urethra  be  carefully  explored, 
that  more  than  one  stricture  exists. 

The  amount  of  contraction  in  cases  of  stricture  varies  greatly,  be- 
tween those  of  large  calibre,  in  which  there  is  but  superficial  thick- 
ening with  loss  of  elasticity  of  the  mucous  membrane,  and  those 
severe  forms  of  long-standing  stricture  in  which  the  lumen  of  the  ure- 
thra is  so  contracted  as  to  resist  the  introduction  of  a  fine  bristle,  even 
when  the  stricture  is  exposed  jjost-mortem.  The  contraction  is  sel- 
dom sufficient  to  completely  prevent  the  passage  of  urine. 

The  explanation  of  the  rarity  of  strictures  impermeable  to  urine 
is  a  very  simple  one.  Every  intelligent  practitioner  knows  how  diffi- 
cult it  is  to  heal  a  fistula  in  the  tissues  which  communicates  with 
secreting  strictures  or  with  a  cavity  containing  materials  which 
escape  and  enter  the  lesion.  Urinary  fistula,  fistula  in  ano,  and  sali- 
vary fistula  are  familiar  illustrations.     The  i)atency  of  urethral  stric- 


508  LYDSTON— DISEASES  OP  THE  MALE  URETHRA. 

ture  is  not  only  facilitated  by  tlie  passage  of  tlie  urine,  but  also  by 
the  fact  that  the  mucous  membrane  is  usually  intact,  or  at  least 
in  part. 

Strictures  impermeable  even  to  instruments  are  also  very  rare, 
particularly  in  the  practice  of  surgeons  who  exhibit  sufficient  pa- 
tience, gentleness,  and  skill  in  instrumentation. 

The  location  of  stricture  has  been  the  subject  of  much  contro- 
versy. Dr.  Otis'  investigations  in  particular  have  modified  in  certain 
quarters  the  existing  ideas  of  the  relative  frequency  of  stricture  at 
different  points  in  the  urethra. 

Until  recently  the  dicta  of  Sir  Henry  Thompson  and  others  of 
his  school  as  to  the  location  of  stricture  have  been  universally  ac- 
cepted. Thompson  found  in  320  cases  of  stricture,  examined  clini- 
cally, 212  which  were  located  at  the  bulbo-membranous  junction,  51  in 
the  spongy  portion  of  the  canal,  at  variable  points  between  one  inch 
anterior  to  the  opening  of  the  triangular  ligament,  and  two  and  one- 
half  inches  posterior  to  the  meatus,  and  54  at  the  meatus  or  within 
two  and  one-half  inches  posterior  to  it.  In  270  cases  examined  post 
mortem,  he  found  a  decided  preponderance  of  stricture  in  the  bulbo- 
membranous  region,  which  he  described  as  the  space  included  be- 
tween a  point  one  inch  anterior  to  the  triangular  ligament,  and  another 
three-fourths  of  an  inch  posterior  to  it.  H.  Smith  examined  98 
preparations  of  stricture  in  the  London  museums,  and  found  only  21 
in  the  membranous  urethra,  the  other  77  being  anterior  to  it.  The 
majority  of  the  latter  were  situated  in  the  bulbous  urethra  or  just  in 
front  of  it.  Otis  claims  that  the  condition  is  most  frequently  found 
in  the  i^enile  portion  of  the  canal.  It  is  obviously  impossible  for  the 
Thompson  and  Otis  schools  to  arrive  at  harmonious  conclusions  as 
long  as  their  standards  of  stricture  and  methods  of  exploration  re- 
main so  widely  different.  Post-mortem  evidence  is  only  relatively 
valuable.  The  surgeon  who  reasons  from  clinical  experience  and  skil- 
fully uses  the  urethrometer  and  bulbs,  can  never  agree  with  Thomp- 
son, and  must  acknowledge  the  accuracy  of  Otis'  methods  even 
though  he  may  consider  the  conclusions  of  the  latter  somewhat  over- 
drawn. It  has  been  my  experience  that  the  most  frequent  site  of 
stricture  appears  clinically  to  be  at  the  meatus  or  just  within  it, 
most  of  these, cases,  however,  being  congenital.  The  next  most  fre- 
quent point  is  the  junction  of  the  bulb  and  fossa  navicularis,  or  just 
posterior  to  it,  i.e.,  two  and  one-half  to  three  inches  from  the  mea- 
tus. The  next  most  frequent  location  is  the  bulbo-membranous 
junction,  and  the  next  about  one  inch  anterior  to  it.  It  seems  to  oc- 
cur with  varying  frequency  in  the  intermediary  portions  of  the  canal. 
From  a  clinical  standpoint,  the  author  has  come  to  regard  stric- 


ORGANIC    STRICTURE.         •  509 

ture  as  any  condition  of  the  urethra  which  is  capable  of  producing 
friction,  by  obstructing  the  flow  of  urine,  to  however  slight  an  ex- 
tent, providing  said  obstruction  and  friction .  are  productive  of 
pathological  disturbances,  or — if  the  latter  have  already  begun — tend 
to  perpetuate  them.  A  point  of  normal  contraction,  or  relative  in- 
elasticity, becomes  a  stricture  only  when  the  urethra  assumes  a  patho- 
logical state ;  the  previously  normal  lack  of  distensibility  is  then  of 
great  pathological  and  surgical  importance,  and  its  removal  may  be 
imperatively  necessary. 

Believing  then  that  any  point  of  contraction  or  inelasticity  in  the 
urethra,  in  the  presence  of  a  pathological  condition  of  the  mucous 
membrane,  constitutes  a  stricture,  the  author  unhesitatingly  reiterates 
his  firm  conviction  that  stricture  of  the  urethra  is  most  frequent  in  the 
pendulous  portion  of  the  canal.  If  care  be  taken  to  exclude  the  ele- 
ment of  deep  urethrismus — which  exclusion  is  not  so  easy  as  some 
authors  would  have  us  believe — the  proportion  is,  the  writer  believes, 
at  least  10  to  1. 

The  prostatic  portion  of  the  urethra  is  never  involved  in  acquired 
stricture  as  far  as  known.  This  immunity  is  due  to  (1)  the  rarity 
of  extension  of  the  acute  inflammation  to  its  mucous  membrane,  and 
(2)  the  distance  of  the  part  from  the  primary  point  of  infection. 

Morbid  Anatomy. 

As  might  be  inferred  from  its  origin,  the  characteristic  changes  at 
the  site  of  a  stricture  are  essentially  those  of  chronic  inflammation. 
Urethritis  having  become  localized  at  some  point  or  points  in  the 
canal,  the  inflammation  extends  to  the  submucous  tissue,  or  if  peri- 
urethral thickening  already  exists,  it  'is  increased ;  the  process  con- 
sisting of  a  submucous  infiltration  of  embryonal  cells,  which  even- 
tually form  a  zone  of  peri-urethral  sclerosis  of  variable  density. 
There  may  or  may  not  be  a  variable  degree  of  infiltration  and 
thickening  of  the  corpus  spongiosum.  The  result  of  the  adventitious 
deposit  is  an  encroachment  upon  the  lumen  of  the  canal  and  a  loss 
of  elasticity  commensurate  with  the  degree  of  the  pathological  pro- 
cess. In  some  instances  there  is  a  slight  thickening  of  the  mucous 
membrane  with  little  or  no  submucous  infiltration,  the  mucous  epithe- 
lium being  lost  to  a  greater  or  less  extent,  and  the  part  covered  with 
muco-purulent  secretion.  The  follicles  of  the  urethra  at  this  point 
are  dilated  and  thickened  and  show  evidences  of  hypersecretion.  At 
a  more  advanced  stage  the  mucous  membrane  becomes  extremely 
thickened,  congested,  and  perhaps  covered  with  fungoid  granulations. 
In  old  aud  pronounced  cases  the  corpus  spongiosum  is  extensively 


510  LYDSTON — DISEASES   OF   THE   MALE   UEETHRA. 

infiltrated  and  of  a  semi-cartilaginous  consistency.  Tlie  condition,  in 
brief,  is  one  of  chronic  interstitial  inflammation.  Bridles,  bands,  or 
flaps  of  thickened  mucous  membrane  may  be  present.  The  degree 
of  occlusion  of  the  canal  is  variable.  In  some  cases  the  process  is 
localized,  perhaps  only  partially  involving  the  circumference  of  the 
canal,  its  lumen  being  very  slightly  contracted.  In  the  more  marked 
forms  the  occlusion  may  be  almost  complete. 

The  secondary  results  of  stricture  are  due  to  three  conditions: 
1.  Mechanical  obstruction  to  the  outflow  of  urine;  2.  Germ  infec- 
tion; 3.  Extension  of  chronic  inflammation.  The  urethra  anterior 
to  the  stricture  may  be  somewhat  contracted,  this  being  due  to  its 
partial  loss  of  function.  Posterior  to  the  stricture  the  urethra  is 
more  or  less  dilated  and  contains  a  greater  or  less  quantity  of  residual 
urine  in  combination  with  the  products  of  infectious  inflammation 
and  decomposition.  This  secretion  alone  or  combined  with  epithelium 
rolled  up  by  the  outflowing  urine  appears  at  the  meatus  in  the  form 
of  a  characteristic  gleety  discharge  or  as  the  so-called  Tripperfaden — 
i.e.,  shreddy  filaments  which  float  about  in  the  urine.  The  secretion 
may  be  mixed  with  more  or  less  blood  if  the  mucous  membrane  be 
extremely  congested.  Crystallization  of  urinary  salts  with  resulting 
urethral  calculus  may  occur  behind  the  stricture.  As  the  case  ad- 
vances, the  mucous  membrane  behind  the  obstruction  becomes  thinned 
and  perhaps  ulcerated.  It  may  give  way  during  a  straining  effort  at 
micturition.  The  infectious  urine  under  such  circumstances  escapes 
into  the  peri-urethral  cellular  tissue  and  produces  abscess  with  re- 
sulting fistula,  or  possibly  infiltration  of  urine  with  acute  septic 
cellulitis  and  death.  All  of  the  glandular  tissues  tributary  to  the 
urethra  are  involved  in  the  chronic  inflammation.  The  urethral 
foUicles,  prostate  glands,  Cow'per's  ducts,  and  the  ejaculatory  ducts 
become  dilated  and  thickened.  The  bladder  is  always  involved  to  a 
greater  or  less  degree.  It  is  mechanically  disturbed  as  a  result  of 
the  backward  prepsure  of  the  urine  during  micturition.  It  is  also 
likely  to  become  affected  by  chronic  inflammation  either  by  exten- 
sion or  by  the  upward  migration  of  germs.  The  bladder  may  be- 
come sacculated,  undergoing  precisely  the  same  changes  as  in  long- 
standing cases  of  prostatic  hypertrophy.  Thickening  of  the  bladder 
waUs,  severe  chronic  cystitis,  vesical  calculus,  and  involvement  of  the 
ureters  and  pelvis  of  the  kidney  are  possible  results.  Pyelitis  with 
or  without  the  formation  of  renal  calculi  will  be  found  to  exist  in  cer- 
tain extreme  cases.  Pyonephrotic  or  perinephritic  abscesses  may 
occur.  In  a  general  way  the  secreting  structure  of  the  kidney  may 
be  said  to  undergo  those  changes  which  are  de'scribed  under  the  om- 
nibus term  "surgical  kidney,"  involving  chiefly  an  interstitial  prolif- 


ORGANIC   STEICTUEE.  511 

eration  of  connective  tissue  and  a  deficiency  of  the  elements  of  the 
normal  stroma.  The  kidney  is  always  more  or  less  hypersemic.  Its 
cortical  structure  may  be  dilated  and  thinned.  The  condition  of  the 
kidney  is  such  that  a  complete  inhibition  of  its  function  may  follow 
a  slight  increase  of  hypersemia.  Reflex  shock  ujjon  such  a  damaged 
kidney  incidental  to  operations  upon  the  genito-urinary  tract,  or 
direct  irritation  from  anaesthetics,  and  particularly  ether,  are  liable 
to  precipitate  ursemic  coma  or  convulsions  and  death. 

The  density  of  the  stricture  varies  with  its  origin,  duration,  and 
the  amount  of  irritation  present.  Traumatic  and  chemical  strictures 
are  typically  cicatricial. 

Symptoms. 

One  of  the  earliest  symptoms  is  disturbance  of  the  function  of 
urination.  This  consists  in  frequency  of  micturition  due  to  two 
causes,  viz.,  (1)  reflex  irritation  of  the  prostatic  urethra  or  of  the 
vesical  neck,  and  (2)  direct  irritation  from  germs  and  their  products 
developing  behind  the  obstruction.  Some  patients  first  consult  the 
surgeon  regarding  increased  frequency  of  micturition  occurring  only  at 
night,  having  been  troubled  in  this  way  perhaps  for  many  years  with- 
out the  development  of  any  other  symptoms.  Strictures  at  or  near 
the  meatus  are  especially  liable  to  produce  reflex  irritation  of  the 
vesical  neck.  Dribbling  of  urine  after  micturition  is  an  early  symp- 
tom. This  is  due  to  interference  with  the  continuous  wave  of  con- 
traction of  the  accelerator  urinse  muscle,  the  function  of  which  is  to 
expel  the  last  few  drops  of  urine.  Imperfect  ejaculation  of  semen 
results  from  a  similar  condition.  The  stream  of  urine  may  be 
forked  or  twisted  according  to  the  form  of  the  stricture.  There  may 
be  several  streams  simultaneously  expelled  from  the  meatus  and  tak- 
ing unusual  and  inconvenient  directions.  The  stream  may  present  a 
fan-shape  or  resemble  very  much  a  stream  of  water  thrown  from  a 
garden  sprinkler.  As  the  case  progresses  the  patient  notices  that  it 
is  necessary  to  bring  into  play  the  auxiliary  action  of  the  abdominal 
muscles  in  micturition.  The  stream  of  water  finally  becomes  very 
small  and  comi)lete  retention  may  at  any  time  occur,  especially  if  the 
patient  be  exj)osed  to  causes  of  spasm  or  congestion  of  the  affected 
part.  Neurotic  symptoms  are  sometimes  fjresent.  Neuralgic  pains 
in  various  situations,  especially  in  the  vicinity  of  the  genito-urinary 
organs,  are  quite  frequent.  Pain  in  the  back,  genito-crural  neural- 
gia, pain  in  the  testes  and  perineum,  and  sometimes  i)ain  reflected  to 
the  anus  and  rectum  are  observed.  Profound  mental  depression  and 
pseudo-impotence  are  occasionally  met  with.  General  malnutrition, 
hypochondria,  and   malaise  are  often  noted.     A  certain   degree  of 


512  LYDSTON — DISEASES   OF  THE  MALE   UEETHKA. 

general  toxremia  is  sometimes  responsible  for  tlie  various  general 
symptoms  present  in  stricture.  This  may  be  of  a  distinctly  nrsemic 
type,  or  due  to  the  absorption  of  toxines  from  tlie  site  of  tlie  lesion 
or  sucli  portions  of  the  genito-urinary  tract  as  may  happen  to  be  the 
site  of  bacterial  action.  One  of  the  most  characteristic  symptoms 
of  stricture  is  a  gleety  discharge.  While  this  discharge  is  by  no 
means  pathognomonic  of  stricture,  it  is  safe  to  assert  that  it  is  in- 
dicative of  that  condition  in  by  far  the  larger  number  of  cases.  Gleet 
should  always  be  regarded  as  symptomatic  and  its  causes  sought  for. 
In  stricture,  the  gleet  may  be  the  perpetuation  of  a  more  or  less 
recent  gonorrhoea,  or  it  may  be  of  recent  development  and  due  to  the 
gradual  encroachment  of  the  adventitious  tissue  uj)on  the  urethral 
lumen  with  resulting  decomposition  of  residual  urine  and  the  devel- 
opment of  chronic  inflammation.  Hemorrhage  during  the  sexual  act 
or  during  micturition  is  an  occasional  symptom. 

Diagnosis. 

The  diagnosis  of  organic  stricture  can  only  be  made  by  instru- 
mental exploration  of  the  canal.  An  essential  requisite  is  a  moder- 
ately capacious  meatus.  It  is  impossible  to  explore  a  canal  of  say 
a  calibre  of  40  French  through  a  meatus  with  a  calibre  of  20.  Otis' 
urethrometer  was  devised  to  overcome  this  objection,  but  it  is  by 
no  means  as  satisfactory  as  the  exploring  bulbs.  The  best  instru- 
ment for  exploration  is  the  mbber  bougie  explorairice  of  Guyon. 
This  has  a  flexible  shaft  and  a  comparatively  hard  bulbous  extremity 
with  an  abrupt  shoulder.  Next  in  value  come  the  exploring  bulbs  of 
Otis.  With  a  good-sized  meatus,  these  bulbous  instruments  enable 
us  to  detect  points  of  contraction  and  tenderness  in  the  urethra  which 
will  be  overlooked  entirely  if  the  ordinary  sound  be  used.  There 
should  be  no  hesitancy  in  incising  the  meatus  if  necessary  for  ex- 
ploratory purposes.  Indeed,  meatotomy  should  be  considered  nec- 
essary as  a  preliminary  in  both  the  diagnosis  and  treatment  of  ure- 
thral disease  in  any  case  in  which  the  meatus  will  not  admit  at  least 
a  30  French. 

With  regard  to  the  measurement  of  the  urethra  for  diagnostic 
purposes,  Dr.  Otis'  method  of  determining  the  calibre  of  the  urethra 
by  the  circumferential  measurement  of  the  penis  is  fallacious.  The 
conditions  governing  the  amount  of  blood  in  the  organ  and  conse- 
quently its  size  are  so  variable  that  the  method  is  necessarily  inac- 
curate. When  it  is  necessary  to  incise  the  meatus  the  operation 
should  be  performed  with  a  blunt-pointed,  straight-backed  bistoury. 

There  are  several  points  aside  from  the  existence  of  obstruction 
which  may  be  determined  by  urethral  exploration.     These  are:   (1) 


ORGANIC  STRICTURE.  513 

The  degree  of  contraction;  (2)  Its  distance  from  the  meatus;  (3) 
By  the  withdrawal  of  the  bougie  its  shoulder  may  be  made  to  impinge 
upon  the  posterior  surface  of  the  stricture,  thus  enabling  us  to  deter- 
mine the  breadth  of  the  obstruction;  (4)  The  number  of  strictures. 
This  is  somewhat  difficult  at  times,  because  one  or  more  of  the  stric- 
tures may  be  so  small  as  to  prevent  the  introduction  of  an  instrument 
large  enough  to  impinge  upon  deeper  obstructions.  This  objection 
does  not  apply  to  the  urethrometer ;  (5)  The  condition  of  the  urethra 
behind  the  stricture  may  be  determined  by  examining  the  secretion 
withdrawn  upon  the  shoulder  of  the  instrument ;  (6)  The  amount  of 
congestion  present  may  sometimes  be  estimated;  (7)  Eesiliency  or 
irritability  of  the  stricture. 

PROaNOSIS. 

This  involves  two  conditions:  First,  its  curability,  and  second, 
its  danger  to  life.  The  possibility  of  a  radical  cure  is  disputed  by 
the  majority  of  surgeons,  the  general  opinion  being  that  a  stricture 
once  formed  is  never  cured.  It  is,  nevertheless,  the  writer's  opinion 
that  a  properly  performed  urethrotomy  is  usually  curative  of  strictures 
in  the  anterior  portion  of  the  canal.  Deeper  strictures  are  more 
difficult  to  cure,  but  even  here  thorough  operation  may  be  followed 
by  permanent  relief.  When  a  stricture  does  not  recontract  to  a 
greater  or  less  degree  within  six  months  or  a  year  after  the  cessation 
of  treatment,  the  prospect  of  a  permanent  cure  is  always  fairly  good. 
Recurrence  after  urethrotomy  takes  place  muc"h  more  readily  in  ca- 
chectic, strumous,  gouty,  rheumatic,  and  syphilitic  patients  than  in 
those  who  are  healthy.  Even  when  dilatation  has  been  successfully 
practised,  the  patient  may  remain  practically  free  from  a  recurrence 
of  his  stricture,  provided  a  sound  be  passed  at  regular  intervals. 

The  prognosis  of  stricture  as  regards  its  danger  to  life  varies  ac- 
cording to  the  duration  of  the  disease,  the  severity  of  its  complica- 
tions and  sequelae,  and  the  method  of  treatment.  The  most  impor- 
tant factor  is  the  condition  of  the  kidneys.  Impairment  of  structure 
and  function  of  these  organs  is  to  be  inferred  in  all  cases  of  organic 
stricture  of  long  standing.  Such  pathological  aberrations  of  the  kid- 
ney are  not  only  immediately  dangerous  to  life,  but  render  all  surgi- 
cal measures  of  treatment  more  or  less  dangerous.  Renal  changes 
are  usually  responsible  for  the  fatal  result  which  ultimately  occurs  in 
neglected  cases  of  severe  stricture. 

Localization. 

The  i)redilection  of  stricture  for  different  poi*tions  of  the  canal 
has  not  been  clearly  explained  by  the  various  authorities  upon  the 
Vol.  I.— 33 


514  LYDSTON — DISEASES   OF  THE  MALE  URETHRA. 

subject.  The  explanation  usually  given  for  tlie  relatively  greater  fre- 
quency of  occurrence  of  stricture  in  various  portions  of  the  canal — 
more  particularly  in  the  bulbo-membranous  region — is  the  presence 
of  a  greater  amount  of  erectile  tissue,  and  a  more  marked  tendency  to 
localization  of  inflammatory  processes  here  than  in  other  portions  of 
the  canal. 

There  are  several  points  to  be  considered  in  the  explanation  of 
the  occurrence  of  stricture  in  any  particular  location,  and  in  some 
instances  there  are  certain  special  elements  in  its  production  which 
are  worthy  of  attention. 

Acqiiired  stricture  at  or  just  within  the  meatus  is  favored  by 
the  existence  of  congenital  narrowing  at  this  point.  There  is  con- 
stant obstruction  to  the  passage  of  urine,  and  the  friction  thereby 
induced  inevitably  enhances  inflammation.  There  is,  moreover,  a 
tendency  to  the  accumulation  of  secretions  behind  it. 

The  introduction  of  the  nozzle  of  the  ordinary  syringe  in  inject- 
ing the  urethra  necessarily  produces  considerable  irritation  when  the 
meatus  is  very  narrow.  These  considerations  explain  the  frequency 
with  which  acquired  stricture  is  found  just  within  the  meatus. 

The  relative  dilatation  of  the  bulbous  portion  of  the  spongy  ure- 
thra and  of  the  fossa  navicularis  undoubtedly  favors  the  retention  of 
a  small  quantity  of  urine  and  of  pathological  discharges  at  these 
points,  but  this  element  in  the  causation  of  stricture  is  not  very  im- 
portant until  actual  obstruction  by  inflammatory  thickening  of  the 
mucous  membrane  occurs  just  in  front  of  the  dilated  point. 

When  stricture  begins  to  form  there  will  inevitably  be  a  small 
quantity  of  urine  left  in  the  canal  after  micturition.  The  author 
believes,  however,  that  this  condition  assumes  little  importance  until 
the  stricture  becomes  very  thick,  as  the  residual  urine  is  not  allowed 
to  remain  undisturbed  for  any  great  length  of  time. 

Strictures  produced  by  injury  to  the  canal  during  the  passage 
of  instruments  necessarily  occur  at  the  site  of  the  lesion  thereby 
produced.  • 

Traumatic  strictures  produced  by  falls  and  blows  upon  the  ure- 
thra correspond  to  the  seat  of  the  injury.  In  the  deep  and  fixed 
urethra  such  strictures  occur  most  frequently  at  the  bulbo-membra- 
nous junction,  for  reasons  already  stated. 

The  location  of  strictures  due  to  the  introduction  of  strong  chemi- 
cal and  caustic  substances  into  the  urethra  is  at  the  site  of  their 
action.  Foreign  bodies  in  the  urethra  may  produce  localized  inflam- 
mation— and  perhaps  ulceration — which  determines  the  site  of  a  sub- 
sequent stricture. 

Injury  incidental  to  chordee  is  often  responsible  for  the  localiza- 


ORGANIC   STRICTURE.  515 

tion  of  stricture.  This  condition  interferes  witli  the  normal  distensi- 
bility  and  elasticity  of  the  urethra,  and  during  erection  produces  a 
strain  and  perhaps  rupture  of  the  corpus  spongiosum  and  urethra  at 
some  particular  point.  This  may  be  produced  by  the  patient  forci- 
bly bending  the  penis.  The  writer  believes  that  it  may  result  also 
from  frequent  and  vigorous  erections. 

By  far  the  most  important  element  in  the  determination  of  stric- 
ture is  the  existence  of  certain  normal  anatomical  peculiarities  of  the 
canal.  This  is  the  chief  bone  of  contention  among  the  warring 
factions  whose  casus  belli  is  the  question,  to  cut  or  not  to  cut. 

It  has  been  shown  by  Weir,  Sands,  and  others  that  there  are  cer- 
tain points  of  narrowing  in  the  spongy  portion  of  the  canal  which 
have  been  termed  by  them  normal  contractions,  these  being  distinct 
from  the  normal  points  of  contraction  usually  recognized,  namely, 
the  meatus,  the  bulbo-membranous  junction,  and  the  point  of  union 
of  the  spongy  urethra  with  the  fossa  navicularis.  This  description 
is  somewhat  misleading.  The  urethra  is  an  elastic  tube  susceptible 
of  considerable  dilatation.  Its  elasticity,  however,  is  not  uniform 
throughout,  but  as  a  consequence  of  sparsity  of  elastic  tissue,  with 
a  preponderance  of  connective  and  fibrous  tissue  in  the  erectile  struc- 
ture of  the  corpus  spongiosum  and  a  deficiency  of  areolar  tissue  be- 
neath the  mucous  membrane,  there  exists  at  various  points  in  the 
canal  relative  inelasticity  and  limited  dilatability  of  the  urethra. 

It  is  well  known  that  in  certain  portions  of  the  canal  relative  in- 
elasticity and  limited  dilatability  are  due  to  certain  anatomical  pecu- 
liarities of  the  surrounding  structures,  e.g.,  at  the  opening  in  the 
triangular  ligament,  the  junction  of  the  fossa  navicularis  with  the 
spongy  urethra,  the  junction  of  the  latter  with  the  bulb,  and  at  the 
meatus.  At  these  various  points  the  areolar  tissue  beneath  the 
mucous  membrane  is  scanty  and  the  latter  is  more  closely  applied  to 
the  tissues  upon  which  it  rests.  There  is  normally  more  strain  at 
these  points  of  narrowing  than  at  any  other  portion  of  the  canal, 
hence  the  urethra  is  here  reinforced  by  an  increased  density  of  fibro- 
connective  tissue. 

In  explaining  the  localization  of  stricture,  we  will  take  as  our 
point  of  departure  the  fact  that  the  urethra  is  a  dilatable  tube,  the 
elasticity  of  which  varies  at  different  points  in  the  canal.  Through 
this  tube  water  at  a  certain  pressure,  and  in  a  certain  volume,  is 
forced  at  more  or  less  frequent  intervals.  Obviously  the  greatest 
friction  is  produced  at  the  various  points  of  normal  contraction  and 
relative  inelasticity.  Against  the  strain  and  friction  produced  at 
these  points  nature  has  provided  a  certain  amount  of  reinforcement 
of  tissue,  and  under  normal  circumstances,  with  a  healthy  mucous 


516  LYDSTON — DISEASES  OF  THE  MAT.E   UKETHRA. 

membrane,  this  pressure  and  friction  do  not  produce  injury.  When, 
however,  the  canal  is  inflamed,  its  lumen  and  elasticity  are  decreased. 
Urine  is  nevertheless  pumped  through  the  tube  in  as  great  a  volume 
and  with  as  great  frequency  as  under  normal  circumstances,  produc- 
ing by  its  mechanical  pressure,  friction,  and  chemical  effects  consid- 
erable irritation,  as  is  evidenced  by  the  consequent  pain  and  smarting. 
Obviously,  the  greatest  amount  of  irritation  occurs  at  the  points  of 
relative  inelasticity  of  the  canal,  and  as  a  consequence  it  is  here  that 
inflammation  tends  to  localize  itself  and  persists, — perhaps  long  after 
the  remainder  of  the  mucous  membrane  has  returned  to  a  condition 
to  a  greater  or  less  degree  approximating  the  normal.  This  chronic 
inflammation  results  in  a  deposit  of  reparative  material,  which  or- 
ganizes and  encroaches  upon  the  lumen  of  the  canal,  forming,  in 
short,  organic  stricture. 

Regarding  the  relation  of  normal  points  of  contraction  to  stricture, 
it  may  be  said  that  such  points  of  relative  inelasticity  and  points  of 
acquired  contraction  may  be  precisely  the  same  from  a  clinical  stand- 
point in  the  presence  of  a  jjathological  condition  of  the  mucous  mem- 
brane. There  is  no  difference  in  results,  and  there  should  be  none 
in  treatment,  between  a  gleet  perpetuated  by  normal  points  of  fric- 
tion and  a  similar  discharge  perpetuated  by  acquired  contraction; 
the  cure  of  the  case  demands  their  removal  independently  of  their 
origin. 

Teeatment. 

General  3Ianagement. — The  successful  treatment  of  stricture  of  the 
urethra  is  dependent  not  only  upon  the  proper  selection  of  surgical 
methods  of  management  and  skill  in  their  application,  but  upon  the 
manner  in  which  the  general  management  of  the  case  is  conducted. 
Careful  attention  on  the  one  hand,  or  neglect  on  the  other,  may 
determine  the  success  or  non-success  of  surgical  treatment.  Thus 
dilatation  may  fail  of  its  object  because  of  irritability  or  resiliency  of 
a  stricture,  which  attention  to  certain  details  in  the  general  manage- 
ment of  the  case  might  avoid.  Urethrotomy,  divulsion,  or  perineal 
section  may  result  fatally  because  of  failure  on  the  part  of  the  surgeon 
to  study  carefully  the  condition  of  other  portions  of  the  genito-urinary 
tract  and  to  appreciate  the  general  and  local  conditions  prevailing  at 
the  time  of  the  operation. 

In  no  disease  of  the  genito-urinary  tract  is  attention  to  genito- 
urinary and  sexual  hygiene  more  essential  than  in  the  management  of 
stricture  of  the  urethra.  Regulation  of  the  diet,  temperate  habits, 
sexual  moderation  or  abstinence,  and  avoidance  of  exposure  to  cold  and 
wet,  are  all  important.     The  use  of  tobacco  should  be  interdicted  as 


OEGANIC   STRICTURE.  517 

tending  to  induce  general  irritability  and  liypersesthesia.  The  writer 
believes,  moreover,  tliat  it  is  especially  irritating  to  the  genito-urinary 
tract.  Cbilling  of  the  feet  and  legs  is  apt  to  be  especially  injurious, 
its  effect  in  producing  acute  hyperaemia  and  inflammation  being 
precisely  similar  to  its  results  in  enlargement  of  the  prostate,  in 
which  disease  the  disastrous  effects  of  exposure  are  so  well  known. 
The  administration  of  alkalies  for  the  purpose  of  neutralizing  the 
urine  is  essential  in  the  majority  of  cases.  When  pronounced  cystitis 
exists,  certain  remedies  will  be  found  beneficial  by  preventing  decom- 
position of  the  urine  and  consequently  lessening  its  irritating  prop- 
erties. Boracic  acid  in  ten-  or  fiiteen-grain  doses  several  times  daily, 
naphthalin,  creosote  in  small  doses,  oil  of  eucalyptus,  benzoate  and 
salicylate  of  soda,  and  in  some  instances  small  doses  of  turpentine, 
are  useful  for  this  purpose.  In  the  author's  experience  the  oil  of 
eucalyptus  in  ten-minim  doses  has  been  of  especial  value;  indeed, 
it  is  the  urinary  antiseptic  'par  excellence.  The  activity  of  the  skin 
should  be  promoted  by  Turkish  baths  and  rubbings.  The  effects  of 
sudden  atmospheric  changes  should  be  avoided  by  wearing  warm 
flannel  garments  of  uniform  weight.  Exercise  should  be  taken  in 
moderation;  fatigue  and  over-exertion  should  be  avoided;  perfect 
rest  may  possibly  be  indicated. 

Certain  local  measures  are  very  essential  in  the  management  of 
stricture.  A  tendency  to  spasm  and  congestion  at  the  site  of  the 
stricture  may  be  prevented  by  the  daily  use  of  hot  sitz-baths  or  the 
occasional  application  of  leeches  to  the  perineum.  As  a  matter  of 
routine,  the  writer  advises  his  patients  to  take  a  hot  sitz-bath 
nightly  before  going  to  bed.  By  proceeding  in  this  manner,  it  will 
be  found  that  the  majority  of  cases  of  stricture  will  be  much  more 
tractable  than  under  ordinary  circumstances.  In  some  cases  of 
very  tough,  resilient  stricture,  the  canal  may  be  dilated  much 
more  readily  if  the  patient  be  directed  to  take  an  injection  of 
water  as  hot  as  can  be  borne  night  and  morning.  These  injec- 
tions should  be  kept  up  for  half  an  hour  at  a  time,  and  may  advan- 
tageously be  made  antiseptic  by  the  addition  of  bichloride  of  mer- 
cury, 1  in  20,000,  or  boric  acid  in  saturation. 

Where  manipulations  of  the  canal  tend  to  excite  urethritis,  hot 
bichloride  irrigations,  as  recommended  for  chronic  urethritis,  may 
be  cautiously  employed.  The  various  balsamic  preparations  are  of 
service  in  such  instances. 

Pain  and  spasm  may  be  excited  by  each  attempt  at  dilatation,  in 
spite  of  the  general  measures  already  recommended.  Under  such 
circumstances,  a  small  dose  of  morphine  may  be  given  hypodermi- 
cally,  by  suppository,  or  by  the  mouth,  a  short  time  before  the  oper- 


518  LYDSTON — DISEASES   OF  THE   T\r^T.F,   UEETHKA. 

ation.  Wlien  eacli  operation  tends  to  produce  urethral  chill  or  fever, 
the  administration  of  opium  has  a  decidedly  conserYative  and  prophy- 
lactic effect.  It  Tvill  be  found  that  in  these  cases  of  ii-ritable  stiicture 
with  a  predisposition  to  urethral  ferer,  thorough  iiTigation  of  the 
canal  with  a  hot  bichloride  solution  before  and  after  the  introduction 
of  a  sound  or. before  cutting  operations,  as  the  case  mar  be,  will  gen- 
erally obviate  the  difficulty.  The  author  would  pai*ticularly  call  at- 
tention to  the  advantages  of  this  procedure,  as  it  will  certainly  tend 
to  prevent  the  septic  element  in  the  production  of  urethral  fever. 
Quinine,  jaborandi,  eucalyptus,  and  diuretin  are  probably  all  ser- 
viceable as  prophylactics  against  chill,  but  eucalyptus  is  the  most 
valuable. 

Selection  of  Method. — The  various  forms  of  treatment  which  have 
been  recommended  for  stricture  are  the  following : 

1.  Caustics. 

2.  Continuous  dilatation. 

3.  Gradual  dilatation. 

4.  Dilating  urethrotomy,  or  a  combination  of  section  and  rupture. 

5.  Divulsion  or  ruptiu'e. 

6.  Internal  urethrotomy. 

7.  External  perineal  section  or  urethrotomy  with  a  guide. 

8.  External  perineal  section  without  a  guide. 

9.  Electrolysis. 

10.  Subcutaneous  section. 

11.  Excision,  with  or  without  a  plastic  operation. 

The  treatment  of  sti'icture  by  caustics  is  a  relic  of  surgical  bar- 
barism, and  is  hardly  worthy  of  serious  attention.  The  objects  for 
which  it  was  originally  recommended  were  (1)  the  destniction  of  the 
strictui'e,  and  (2)  diminution  of  the  sensibility  of  the  mucous 
membrane  for  the  purpose  of  allaying  irritability  and  spasm  of  the 
canal.  The  substance  used  was  generally  caustic  potash.  TMiatever 
the  results  may  have  been,  as  far  as  restoring  temporarily  the  calibre 
of  the  canal  was  concerned,  the  inevitable  consequence  of  such  atro- 
cious surgery  must  necessarily  have  been  the  substitution  of  a 
chemical  stricture  for  an  ordinary  organic  one.  As  is  well  known, 
stricture  due  to  actual  destniction  of  tissue  is  the  most  severe  form 
with  which  we  are  called  upon  to  deal.  All  the  other  methods  of  treat- 
ment which  have  been  enumerated  have  their  advocates  at  the  present 
day — either  as  a  matter  of  routine  or  a  range  of  treatment  from  which 
to  make  a  selection — and  may  under  proper  circumstances  be  prac- 
tised with  advantage  in  different  cases.  The  selection  of  the  method 
is  necessarily — -udthin  certain  limits— a  matter  of  choice  on  the  part 
of  the  individual  surgeon.      The   various    legitimate  methods  will 


ORGANIC   STRICTURE.  ,  519 

receive  special  consideration  after  their  applicability  to  the  various 
forms  of  stricture  lias  been  outlined. 

Of  the  various  methods  enumerated,  there  are  but  two  which  in 
the  opinion  of  the  author  require  serious  consideration,  these  being 
dilatation,  continuous  or  systematic,  and  urethrotomy,  internal  and 
external. 

For  practical  purposes  the  surgical  treatment  of  urethral  stricture 

may  be  divided  into  that  of — 

a.  Simple     uncomplicated 
stricture. 

b.  Irritable  stricture. 

As  re-     i  2.   Stricture  of  the  penile        ,  .        '■    ^f  Kent  and  elastic  stric- 

J    1  .,  ^  As  regards  ture. 

gardslo-  i        _  urethra.  _        ^  .1,...^,^.     i  rJ,  Recurrent  stricture. 

.    Dense  and  hard  tortuous 


f  1.  Stricture  of  the  meatus. 


cation.     |  3.   Stricture  of  the  deep 
^^  urethra. 


stricture. 
/.    Complicated  stricture. 
g.   Traumatic  stricture. 


To  a  certain  extent  the  treatment  of  each  particular  case  is  modified 
by  the  calibre  of  the  contraction;  for  example,  in  tight  strictures 
which  it  seems  advisable  to  treat  by  sounds,  metallic  instruments 
should  not  be  used  until  a  moderate  amount  of  dilatation  has  been 
attained.  The  treatment  is  further  modified  by  the  occurrence  of 
complications,  such  as  false  passages,  retention  of  urine,  severe 
cystitis  and  pericystitis,  infiltration  of  urine  and  abscess,  fistulse, 
enlarged  prostate,  etc. 

Stricture  of  the  Meatus. — This  demands  division  by  the  knife  ir- 
respective of  the  cause  of  the  stricture.  In  the  presence  of  a  patho- 
logical condition  of  the  urethra,  any  meatus  which  prevents  the  in- 
troduction of  an  instrument  of  sufficient  size  to  distend  the  remainder 
of  the  canal  to  its  extremest  capacity,  should  be  considered  as  strict- 
ured.  The  incision  should  always  be  made  in  a  downward  direction, 
and  if  care  be  taken  to  divide  all  strictured  bands  behind  the  ex- 
ternal orifice  with  the  belly  of  the  knife,  a  sufficiently  large  meatus 
can  always  be  obtained  without  the  production  of  deformity.  The 
after-treatment  of  meatotomy  consists  in  dilatation  every  second  day 
until  healing  has  taken  place. 

Stricture  of  the  Penile  Urethra. — Strictures  in  the  penile  portion  of 
the  urethra  when  recent  and  soft  may  yield  to  dilatation.  Strictures 
of  large  calibre,  the  foundation  of  which  is  a  normal,  or  at  least 
a  congenital,  point  of  relative  inelasticity  of  the  canal,  are  not  likely 
to  yield  to  dilatation.  The  author  believes  that  his  experience  justi- 
fies hira  in  asserting  that  in  by  far  the  larger  proportion  of  cases  of 
penile  strictures  the  gleety  discharge  characteristic  of  such  conditions 
usually  continues — perhaps  with  acute  exacerbations — until  the  ure- 
thra lias  been  x)ut  completely  at  rest  arid  the  source  of  irritation  re- 


520  LYDSTON — DISEASES  .OF  THE  MALE   UEETHEA. 

moved  by  uretlirotomy.  If  the  penile  stricture  be  very  tiglit,  pre- 
liminary dilatation  is  usually  preferable  to  an  extensive  primary  ure- 
throtomy. Strictures  of  the  penile  portion  of  j;he  canal  are  quite  likely 
to  be  multiple.  When  such  strictures  are  irritable,  as  they  are  likely 
to  be,  very  slight  causes  are  sufficient  to  produce  a  urethritis,  the 
severity  of  which  depends  upon  the  degree  of  irritation.  The  pres- 
ence of  reflex  sj'mptoms  referable  to  the  prostate,  bladder,  or  kidney 
invariably  demands  urethrotomy. 

Operation. — Extensive  experience  has  demonstrated  to  the  author 
that  the  method  of  dilating  urethrotomy,  as  perfected  by  Otis  and  per- 
formed with  the  instrument  which  he  has  devised,  is  upon  the  aver- 
age the  simplest,  safest,  and  most  successfid  method  of  treatment  of 
penile  strictures.  The  author  has  devised  a  series  of  bulbs  with  a 
cutting  blade,  which  are  often  preferable  to  the  dilating  urethrotome 
in  slight  linear  strictures ;  but  the  stand-by  of  the  surgeon  is  the  in- 
strument of  Otis.  In  the  performance  of  the  operation  the  strictest 
asepsis  shoidd  be  maintained.  The  surgeon  shoidd  be  as  careful  of 
his  instruments  and  hands  as  though  he  were  about  to  enter  the  ab- 
dominal cavity.  The  urethra  should  be  flushed  with  a  1-10,000  to 
1-20,000  solution  of  bichloride  of  mercury  as  a  preliminary  step  in 
the  operation.  The  operation  may  be  done  under  cocaine  in  most 
instances.  The  author  uses  a  solution  of  two  per  cent,  cocaine  and  one 
per  cent,  carbolic  acid.  This  appears  to  be  safe  and  is  quite  as 
efficient  as  stronger  solutions.  It  is  not  best  to  lay  down  any  arbi- 
trary rules  for  the  performance  of  the  operation.  The  size  to  which 
the  urethra  should  be  enlarged  is  to  be  determined  by  the  personal 
equation.  The  largest-sized  instrument  which  the  meatus  will  admit, 
when  incised  to  the  fullest  capacity  possible  without  the  production 
of  serious  deformity,  is  in  a  general  Avay  a  safe  criterion  of  the  size  of 
the  instrument  which  the  rest  of  the  urethra  will  admit.  It  is  the 
custom  with  some  surgeons  to  use  the  retained  catheter  after  internal 
urethrotomy.  This,  however,  is  not  necessary  in  the  majority  of  in- 
stances. Systematic  dilatation  is  necessary  after  the  operation  in 
order  to  prevent  recontraction  and  to  secure  smooth  healing  of  the 
wound.  The  instrument  should  not  be  passed,  as  a  rule,  before  the 
third  day,  and  when  there  is  much  inflammation  it  is  perfectly  safe 
to  allow  the  urethra  to  remain  undisturbed  for  from  five  to  seven  days. 
It  should  be  dilated  thereafter  at  intervals  of  three  or  four  days, 
which  interval  is  gradually  increased.  Dilatation  should  be  persisted 
in  for  from  four  to  six  weeks  or  longer,  according  to  the  exigencies  of 
the  case.  The  author  desires  to  lay  special  emphasis  upon  the 
fact  that  sounding  is  usually  performed  too  soon  and  too  fre- 
quently after  urethrotomy. 


ORGANIC   STRICTURE.  521 

In  the  author's  monograph  upon  stricture  of  the  urethra,  the 
treatment  of  strictures  of  the  penile  urethra  is  summed  up  as  follows : 

1.  Those  located  within  two  and  one-half  inches  from  the  meatus 
cannot  possibly  be  cured  by  dilatation,  and  must  be  cut. 

2.  Pronounced  cases  in  any  portion  of  the  penile  urethra  must  be 
cut  either  immediately  or  after  preliminary  dilatation,  in  by  far  the 
majority  of  cases. 

3.  The  treatment  of  marked  cases  of  small  calibre  may  be  begun 
by  continuous  or  gradual  dilatation  with  soft  instruments  up  to  the 
size  of  15  or  16  French,  or  even  larger,  and  in  some  cases  it  may  be 
advisable  to  continue  the  dilatation  with  soft  instruments  beyond  this 
point,  until  the  stricture  shows  irritability. 

4.  Strictures  of  large  calibre,  strictures  of  recent  formation,  and 
those  consisting  of  points  of  normal  inelasticity  which  are  perpetuat- 
ing gleet,  may  be  treated  by  dilatation,  the  patient  being  forewarned 
that  the  treatment  may  prove  unsuccessful,  and  that  urethrotomy  will 
probably  be  required  either  within  a  short  time,  or  later  on,  on 
account  of  a  recurrence  of  urethritis  dependent  upon  the  contraction. 
In  other  words,  the  patient  should  be  informed  that  the  treatment  by 
dilatation,  although  it  may  prove  efficacious  in  temporarily  relieving 
the  gleet  and  other  symptoms  of  stricture,  may  at  the  same  time  fail 
to  produce  a  permanently  satisfactory  result,  and  that  he  will  con- 
stantly be  predisposed  to  attacks  of  inflammation  from  the  slightest 
indiscretion.  Should  the  patient  be  satisfied  with  treatment  of  this 
kind,  it  is  hardly  wise  for  the  surgeon  to  insist  upon  an  operation. 

Respecting  the  prognosis  after  internal  urethrotomy,  the  author 
desires  to  express  his  faith  in  the  permanency  of  the  result  in  the 
majority  of  cases,  if  the  operation  be  properly  performed. 

Stricture  of  the  Deep  Urethra. — This  condition  implies  those  stric- 
tures which  involve  the  bulbo-membranous  region.  They  are  generally 
the  most  serious  form,  the  gravity  of  the  stricture  being  directly  pro- 
portionate to  its  distance  from  the  meatus.  In  selecting  the  method 
of  treatment  for  deep  stricture,  it  should  be  remembered  that  no 
method  has  yet  been  generally  accepted  as  affording  a  prospect  of  a 
X^ermanent  cure.  Inasmuch,  therefore,  as  radical  operations  do  not 
promise  a  great  deal,  we  should  lean  toward  conservatism.  It  is  to 
be  understood,  however,  that  many  cases  occur  in  which  conserva- 
tism may  be  dangerous.  The  author  holds  that  perineal  section 
offers  a  better  prospect  of  radical  cure  than  is  generally  believed,  and 
that  it  should  l^e  oftener  performed. 

Simj)le,  soft,  uncomx)licated  stricture  of  the  deep  urethra  should 
be  treated  by  dilatation.  If  the  stricture  be  of  small  calibre,  con- 
tinuous dilatation  with  soft  instruments  may  be  practised  at  first. 


522  LYDSTON — DISEASES   OF  THE  MALE  URETHRA. 

As  soon,  however,  as  it  is  possible  to  introduce  moderately  large 
steel  instruments  tliey  should  be  used.  Continuous  dilatation  may 
be  practised  for  from  twenty -four  to  forty-eight  hours  in  very  tight 
strictures,  and  intermittent  dilatation  by  soft  instruments  maj-  be 
practised  daily,  or  every  second  or  third  day  thereafter.  Sys- 
tematic dilatation  by  steel  instruments  should  not  be  practised  as  a 
rule  oftener  than  once  in  every  three  or  four  days,  an  interval  of 
from  five  to  seven  days  being  often  advantageous.  Traumatic  stric- 
ture of  the  deep  urethra  generally  demands  perineal  section. 

Irritable  Stricture.  — In  this  form  of  the  disease  the  patient  is  usually 
of  a  strongly  nervous  and  highly  irritable  temperament,  and  the  ure- 
thra extremely  hypersesthetic.  Dilatation  produces  severe  pain  and 
spasm,  and  is  often  followed  by  chill  and  perhaps  fever.  Such  stric- 
tures require  urethrotomy.  Besilient  and  elastic  stricture  is  a  con- 
dition in  which  the  obstruction  is  apparently  dilated  quite  readily, 
but  the  symptoms  are  not  relieved,  and  on  exploration  with  the  [bulb 
the  coarctation  is  found  to  be  still  present.  Urethrotomy  is  the  sine 
qua  non  in  this  condition  also.  Recurrent  stricture  is  really  a  variety 
of  resilient  stricture  in  which  the  property  of  resiliency  is  not  imme- 
diately manifested,  the  symptoms,  however,  recurring  very  soon  after 
apparently  successful  dilatation.  The  cutting  operation  is  the  only 
means  of  relief  in  this  condition.  The  hard,  so-called  nodular  stric- 
tures of  cartilaginous  consistency  and  long  duration  which  are  occa- 
sionally met  with  in  the  deep  urethra,  require,  as  a  rule,  perineal 
section.  The  same  is  true  of  hard  and  tortuous  strictures  with  com- 
plications, and  in  cases  in  which  economy  of  time  is  necessary,  or  in 
which  the  condition  of  the  patient  is  such  as  urgently  to  demand  re- 
lief. Traumatic  stricture  can  rarely  be  relieved,  save  by  urethrotomy. 
The  author  desires  to  place  himself  upon  record  as  opposed  to  in- 
ternal urethrotomy  and  divulsion  of  deep  urethral  strictures.  Peri- 
neal section  is  much  more  surgical,  quite  aseptic  by  comparison,  and 
places  the  field  of  operation  under  approximately  perfect  control. 
There  are,  to  be  sure,  occasions  when  both  divulsion  and  internal 
urethrotomy  may  be  justifiable,  but  these  instances  are  certainly 
rare. 

Electrolysis  has  received  considerable  attention  as  a  method  of  treat- 
ment for  urethral  stricture.  It  is  the  opinion  of  the  author  that  this 
method  of  treatment  has  a  very  limited  application.  It  is  not  to  be 
condemned  in  toto,  but  the  claims  which  are  made  for  it  by  some  of 
its  enthusiastic  advocates  are  certainly  very  much  exaggerated.  That 
it  will  in  certain  instances  relieve  what  the  author  has  termed  plus  con- 
ditions of  stricture,  viz.,  congestion,  spasm,  and  oedema,  is  probable. 
When  these  conditions  are  removed,  however,  we  are  still  confronted 


BIBLIOGRAPHY. 


623 


■with  the  presence  of  adventitious  tissue  constituting  the  true  element 
of  the  stricture.  Upon  this  the  author  firmly  believes  the  electrolytic 
current  has  very  little  effect  within  the  limits  of  safety. 

Further  discussion  of  the  eminently  surgical  topic  of  the  treat- 
ment of  urethral  stricture  is  hardly  warrantable  in  a  work  intended 
primarily  for  the  physician.  The  author  will,  therefore,  sum  up  the 
treatment  of  the  disease  by  presenting  the  following  resume  which 
has  appeared  in  his  monograph  upon  urethral  stricture : 


1.  Simple  stricture,  small  calibre, 
or  large  calibre. 

2.  Kesilient,    elastic    and    recur- 

rent stricture. 

3.  Hard,  tortuous,  old,  and  com- 

plicated stricture. 

4.  Traumatic  stricture. 


5.   Stricture  complicated    by    re- 
tention. 


Continuous    dilatation,    followed    by   gradual 

dilatation. 
Gradual  dilatation. 
Internal    dilating      urethrotomy      (exception- 

ally). 
Divulsion  (exceptionally) . 
Perineal  section  (usually). 

External  urethrotomy  or  perineal  sec- 
tion. 

Dilatation  (very  rarely) . 

Internal  urethrotomy  (rarely) . 

Divulsion  (rarely). 

Perineal  section  (usually) . 

Relieve  the  retention  and  temporize  if  possible. 
Begin  dilatation  as  early  as  practicable. 

Perineal  section  if  operation  is  urgently  neces- 
sary. 

Divulsion  as  the  operation  of  necessity  when 
no  other  means  are  at  hand. 

Electrolysis,  i.e.,  galvanism  as  a  temporary 
measure.  This  is  to  be  followed  by  dilata- 
tion or  urethrotomy  as  occasion  requires. 


Bibliograpliy. 

Acton,  W.  :  A  Complete  Practical  Treatise  on  Venereal  Diseases,  etc.  New 
York,  1848. 

Bumstead,  F.  J.,  and  Taylor,  R.  W.  :  The  Pathology  and  Treatment  of  Venereal 
Diseases.     New  York,  1874. 

Culver,  E.  M. ,  and  Hayden,  J.  R.  :  A  Manual  of  Venereal  Diseases.  Philadel- 
phia, 1891. 

Dittel,  Leopold  :  Die  Stricturen  der  Harnrohre.     Stuttgart,  1880. 

Finger,  Ernest:  Blennorrhcea  of  the  Sexual  Organs  and  its  Complications.  Third 
edition.     New  York,  1894. 

Fllrbringer,  P.  :  Traite  des  Maladies  des  Organes  Genito-urinaires.     Paris,  1892. 

Gross,  S.  D.  :  A  Practical  Treatise  on  the  Diseases,  Injuries,  and  Malformations 
of  the  Urinary  Bladder,  the  Prostate  Gland,  and  the  Urethra.  Second  edition. 
Philadelphia,  1855. 

Guyon,  J.  C.  F.  :  Ler^ons  Cliniques  sur  les  Maladies  des  Voics  Urinaires.  Sec- 
ond edition.      Paris,  1885. 

Harrison,  Reginald  :  Lectures  on  the  Surgical  Disorders  of  the  Urinary  Organs. 
Second  edition.      London,  1880. 

Hunter,  Jolin  :  A  Treatise  on  the  Venereal  Disease ;  with  Additions  by  P.  Ri- 
cord.     Edited  with  Notes  by  F.  J.  Bumstead.     Philadelphia,  1853. 


524  LYDSTON — DISEASES  OF  THE   MALE  URETHRA. 

Jamin,  P.  :  Annales  des  Maladies  Genito-urinaires,  1893. 

Lydston,  G.  Frank :  Urine  Fever.     Medical  Register,  1888. 

Injuries  of  the  Urethra.     Medical  and  Surgical  Reporter,  May,  1887. 

Gonorrhoea.     Medical  Age,  Oct.  10,  1889.. 

Evolution  of  the  Local  Venereal  Diseases.      Medical  Record,  March 

15,  1890. 

Gonorrhoea  in  the  Female.     Medical  Mirror,  Jan. ,  1890. 

Observations  on  Urethral  Stricture.     Chicago  Medical  Recorder,  Nov. , 

1891. 

Treatment  of  Posterior  Urethritis  by  Irrigation  Without  Tube  or  Cath- 
eter.    International  Medical  Magazine,  Sept.,  1893. 

Gonorrhoea  and  Urethritis,  1892. 

Stricture  of  the  Urethra,  1892. 

Remarks  on  So-called  Urethral  Fever.     Chicago  Medical  Recorder,- 

Dec,  1892. 

Milton,  J.  L.  :  On  the  Pathology  and  Treatment  of  Gonorrhoea  and  Spermator- 
rhoea.    New  York,  1887. 

Otis,  F.  N.  :  On  Stricture  of  the  Male  Urethra,  its  Radical  Cure.  Third  edition. 
New  York,  1880. 

Ricord,  Phillipe  :  Traite  Complet  des  Maladies  Veneriennes.     Paris,  1851. 

Sinclair,  W.  J.  :  On  Gonorrhceal  Infection  in  Women.  Medical  and  Surgical 
Monographs,  vol.  i..  No.  2.     New  York,  1889. 

Thompson,  Sir  H.  :  The  Pathology  and  Treatment  of  Stricture  of  the  Urethra 
both  in  the  Male  and  Female.     Fourth  edition.     London  and  Philadelphia,  1885. 

Van  Buren,  W.  H. ,  and  Keyes,  E.  L.  :  A  Practical  Treatise  on  the  Surgical 
Diseases  of  the  Genito-Urinary  Organs.  Revision  by  E.  L.  Keyes.  New  York, 
1890. 

Vidal  (de  Cassis),  A.  T.  :  A  Treatise  on  Venereal  Diseases.  Third  edition. 
New  York,  1865. 


DISEASES  OF  THE  URINE. 


BY 


E.  HUERY  FENWICK, 


LONDON. 


DISEASES   OF  THE  URINE. 


In  the  following  article  upon  certain  morbid  changes  in  the  urine 
it  has  been  deemed  exijedient  in  each  case  to  revert  to  the  old-fash- 
ioned custom  of  raising  a  symptom  to  the  rank  of  a  disease.  It  is 
true  that  common  sense  and  experience  combine  in  prohibiting  us 
from  giving  undue  prominence  to  any  single  symptom,  but  in  dealing 
with  urinary  diseases  the  advantage  to  be  gained  by  taking  this 
course  of  action  is  undoubtedly  great.  Not  infrequently  the  admix- 
ture of  phosphates,  urates,  blood  or  pus  with  the  urine  constitutes 
the  most  salient,  often  the  only  evidence  that  changes  in  the  func- 
tional or  organic  integrity  of  some  part  of  the  urinary  tract  are  in 
progress.  A  clue  line  is  thus  at  once  presented  to  us,  which,  if  it  is 
properly  utilized,  wiU  often  lead  to  a  correct  determination  of  the 
locality  and  the  character  of  the  morbid  condition  demanding  altera- 
tion or  treatment. 

H-ffiMATURIA.* 

Definition. — Blood  derived  from  any  part  of  the  urinary  system — 
whether  from  the  secreting,  conducting,  or  collecting  divisions — and 
passed  pure  or  mixed  with  the  urine,  constitutes  the  symptom  known 
as  hsematuria. 

This  symptom,  though  occurring  at  one  time  or  other  in  the 
course  of  all  the  more  serious  diseases  affecting  the  urinary  organs, 
has  not  received  that  attention  at  the  hands  of  urologists  which  its 
importance  demands.  This  neglect  is  perhaps  accounted  for  by  the 
fact  that  until  qiiite  recently  the  origin  and  cause  of  blood  appearing 
in  the  urine  could  not  be  diagnosed  with  certainty. 

Its  prognosis  was  moreover  uncertain  and  its  treatment  was  em- 
pirical and  hajjhazard. 

Up  to  the  date  of  the  introduction  of  electric  illumination  of  the 
bladder  in  1888  by  Max  Nitze  all  our  experience  of  the  obscure  dis- 
eases of  the  urinary  tract  was  obtained  slowly  and  with  difficulty, 

*  For  the  sake  of  clearness  a  consideration  of  the  conditions  known  as  hsemo- 
globlnuria  and  intermittent  hscmatinuria  (paroxysmal  hasmoglobinuria)  have  not 
been  included  in  this  section,  but  are  to  be  found  elsewhere. 


528  FENWICK — DISEASES  OF  THE   UEIKE. 

for  it  was  acquired  either  by  post-mortem  examination  or  by  opera- 
tive interference.* 

The  cystoscope  of  to-day  has,  however,  changed  all  this,  for  it  en- 
ables the  surgeon  in  a  very  large  number  of  cases  of  hsematuria  not 
only  to  locate  the  source  of  the  hemorrhage,  but  often  to  determine 
its  cause,  while  it  enables  him  at  the  same  time  to  treat  it  rationally 
and  successfully. 

But  the  electric  cystoscope  is  neither  suitable  nor  available  in 
general  medical  practice,  for  this  instrument  demands  considerable 
tactile  dexterity,  much  judgment,  and  some  knowledge  of  electrical 
technique.  Its  emploj^ment,  therefore,  is  not  advocated  in  this  arti- 
cle, and  it  has  been  attempted  to  incorporate  the  knowledge  which 
has  been  acquired  by  its  means  in  such  a  manner  as  to  render  endo- 
scopy as  superfluous  as  possible. 

Causes  of  H^matueia. 

Blood  appears  in  the  urine  from  a  varietj^  of  causes,  which  are  of 
constitutional  or  of  local  origin.  The  tabulated  lists  usually  given 
in  text-books  embrace  many  causes  which  the  practitioner  will  not 
meet  with  once  in  a  life-time,  and  many  which  are  mythical,  f  Al- 
though the  following  lists,  which  I  have  drawn  up  from  accurate  cys- 
toscopic  records  of  my  own  cases,  can  be  of  comparatively  little  value 
in  depicting  the  frequency  of  the  various  forms  of  hsematuria  which 
will  be  met  with  in  routine  work,  yet  they  are  probably  as  near  the 
mark  as  can  possibly  be  obtained. 

If  the  bleeding  of  gonorrhoeal  prostatitis  and  ordinary  nephritis 
be  excluded,  the  first  hundred  cases  of  hsematuria  which  I  examined 
with  the  electric  light  in  routine  hospital  treatment  showed  the  fol- 
lowing groupings : 

Tumors  of  the  bladder 31  cases. 

Renal  disease,  including  carcinoma,  tubercle,  stone,  syphilis. ...  24 

Tubercular  and  other  forms  of  ulceration  of  the  bladder 22 

Hemorrhagic  cystitis 12 

Encysted  vesical  stone 5 

Prostatic  hemorrhage 4 

Uncertain 2 

Total 100 

*  Sir  Henry  Thompson  (Lectures  1884,  p.  32) ,  after  advocating  digital  explora- 
tion of  the  bladder  in  obscure  cases,  says :  "  Indeed,  it  Is  difficult  to  say  what  may 
not  be  found,  as  fresh  experiences  have  brought  to  light  conditions  to  some  extent 
not  hitherto  recognized.  Hence  there  are  few  occasions,  J  confess,  which  for  me 
have  excited  a  more  lively  interest  than  the  moment  at  which  my  finger  enters  a 
bladder,  the  condition  of  which  has  been  a  theme  of  keen  inquiry  and  speculation 
for  some  months  or  even  for  years  before.  " 

f  The  days  have  gone  when  we  could  content  ourselves  with  the  diagnoses,  given 


DIAGNOSIS  OF   URINAIIY  HEMORRHAGE.  529 

Probably,  however,  as  tliese  were  routine  hospital  patients  they 
would  not  offer  the  same  difficulty  in  diagnosis  as  those  who  were 
sent  by  practitioners  for  special  examination.  Taking  fifty  such 
cases  in  which  doubt  as  to  the  cause  existed,  the  following  were  the 
cystoscopic  diagnoses : 

Tumors  of  the  bladder 24  cases. 

Stone  in  the  bladder 10     " 

Stone  in  the  kidney 6      " 

Tubercle  of  the  bladder 3 

Tubercle  of  the  prostate 2 

Renal  carcinoma 3 

Cystitis 2 

Enlarged  prostate 1 

Total 50 

In  order  to  treat  hsematuria  with  judgment  and  precision  its 
source  and  cause  must  first  be  ascertained.  In  actual  practice  the 
mental  problems  of  determining  the  locality  and  the  cause  are  re- 
volved almost  simultaneously,  and  for  the  sake  of  conciseness  and 
logical  sequence  they  are  considered  together. 

Diagnosis  of  the  Source  and  Cause  of  Urinaey  Hemorrhage. 

The  objective  signs  and  subjective  sj^mptoms  furnished  by  each 
patient  permit  of  certain  guidance  rules  being  framed  for  the  deter- 
mination of  the  source  and  cause  of  the  bleeding.  These,  though 
by  no  means  infallible,  may  be  accepted  as  reliable.  They  are  based 
upon  (A)  Examination  of  the  urine ;  (B)  Examination  of  the  patient ; 
(C)  Critical  examination  of  the  symptoms  complained  of. 

A.— Examination  of  the  Urine. 

(1) .  The  Color — Some  knowledge  may  be  gleaned  from  the  color 
of  the  urine. 

Axiom :  "  The  brighter  and  more  arterial  the  color  of  the  urine, 
the  nearer  the  source  of  the  bleeding  is  to  the  meatus  urinarius." 

Qualification:  This  is  correct  to  a  great  extent,  but  it  must  be 
remembered  that  in  severe  injuries  to  the  kidney,  and  in  some 
cases  of  renal  sarcoma  and  carcinoma,  the  blood  is  poured  out  so 
rapidly,  and  enters  the  bladder  in  such  large  quantities,  that  it  is 
expelled  therefrom  almost  as  bright  in  color  as  when  it  issued  from 
the  rupture  or  from  the  vascular  growth. 

If,  then,  traumatism  of  the  kidney  and  renal  tumor  before  the  age 

and  maintained  by  the  older  physicians  without  basis,  of  "ngevus  of  the  bladder,  " 
•'the  ha;maturia  of  mental  emotion,  of  bodily  exertion,  of  vicarious  menstruation,  " 
and  such  like. 

Vol.  I. -34 


'530  FENWICK — DISEASES  OF  THE  UBINE. 

of  five  or  over  forty-five  be  excluded,  bright  arterial  bleeding  usually 
emanates  from  tlie  lower  urinary  passages. 

Fallacy :  There  are  some  pitfalls  which  must  be  exposed.  It  is 
taught  that  smoky  or  beef-tea-looking  urine  is  always  renal  in  its 
source,  "  because  of  the  action  of  the  acid  urine  upon  the  haemoglobin 
of  the  blood. "  If  this  colored  urine  is  accompanied  by  other  signs 
of  renal  disease,  such  as  casts,  excess  of  albumin,  and  lowered  speci- 
fic gravity,  the  color  indication  is  correct,  but  without  these  corrob- 
orative evidences  it  is  a  fallacy  to  diagnose  a  renal  source  solely  upon 
the  color  of  the  urine.  This  pitfaU  must  be  studiously  avoided,  es- 
pecially in  the  male  subject. 

A  small  amount  of  blood  leaking  into  the  bladder  in  any  form  of 
atony  (such  as  that  induced  by  stricture  or  prostatic  enlargement) 
causes  the  urine  to  assume  a  beef-tea  color,  for  the  blood  remains  for 
some  time  in  contact  with  the  residual  urine  left  in  the  viscus  by  in- 
efficient expulsion.  Moreover,  in  certain  cases,  although  there  is 
no  residual  urine,  the  blood  leaks  from  an  abraded  surface  so  slowly 
that  it  becomes  mixed  with  a  large  amount  of  the  healthy  secretion. 
It  is,  therefore,  voided  merely  "smoky." 

Still  more  incorrect  is  it  to  insist  upon  a  renal  source  because 
the  blood  is  coflfee-colored  or  black.  The  best  example  of  "black 
bloody  urine"  is  to  be  found  in  cases  of  profuse  hemorrhage  into 
the  bladder  accompanied  by  retention  from  clotting.  It  varies  under 
these  circumstances  from  the  color  of  porter  to  a  jet-black. 

I  could  quote  many  cases  illustrative  of  a  wrong  diagnosis  of 
renal  disease  having  been  given,  upon  the  ground  that  the  iirine  was 
dark  in  color.     One  struck  me  especially : 

A  lady  aged  fifty-two,  of  sedentary  habits,  had  been  in  the  habit 
of  passing  coffee-colored  urine  at  rare  intervals  during  two  and  a  half 
years.  Her  medical  attendant  had  persistently  treated  her  for  kid- 
ney disease.  One  day  she  was  suddenly  forced  to  take  a  long  rail- 
way journey,  and  in  consequence  probably  of  this  unusual  amount  of 
exertion  she  began  to  pass  very  bright-colored  blood  and  clots.  Sus- 
picions were  at  once  aroused  that  the  source  of  hemorrhage  was  the 
bladder,  and  I  was  asked  to  use  the  cystoscope.  A  large  villous  pa- 
pilloma the  size  of  a  tangerine  orange  was  discovered  in  a  very 
capacious  bladder.     It  was  removed  and  the  patient  recovered. 

This  mistake  is,  I  believe,  the  more  readily  made  in  early  stages 
of  the  harder  forms  of  carcinoma  of  the  male  bladder.  The  malaise 
or  initial  irritability  of  the  bladder  induces  the  practitioner  to  test 
the  urine.  Albumin  to  a  slight  amount  is  discovered  in  clear  urine ; 
this  albumin  is  due  either  to  serous  leakage  from  the  latent  growth 
or  to  a  microscopic  escape  of  blood.     The  practitioner  assumes  it  to 


DIAGNOSIS  OF  URINARY  HEMORRHAGE.  631 

be  from  tlie  kidney,  and  later  on,  when  the  vesical  growth  begins  to 
bleed  slightly  into  acid  urine,  and  coffee-colored  or  beef-tea-like  urine 
is  passed,  the  diagnosis  of  a  renal  source  is  supposed  to  be  con- 
firmed, and  it  is  only  a  month  or  two  later,  when  a  sharp  rush  of 
bright-colored  blood  appears,  that  the  bladder  is  examined  and  the 
diagnosis  is  corrected. 

(2)  The  Shape  of  the  Glot. — Much  information  can  be  gathered 
by  floating  in  water  the  clots  which  are  passed  by  the  patient. 

Axiom  i. :  "  Long,  dark  clots  like  earthworms*  or  quill-barrels  indi- 
cate bleeding  from  the  renal  pelvis,  for  they  are  casts  or  moulds  of 
the  ureter."  '  All  uncertainty  is  set  at  rest,  however,  if,  after  a  tran- 
sient cessation  of  the  hemorrhage,  long  worm-like  clots  are  passed 
partially  decolorized,  and  if  this  is  followed  by  a  recurrence  of  the 
bleeding.  It  is  thus  demonstrated  beyond  doubt  that  the  ureter  has 
been  completely  plugged  and  the  hemorrhage  checked  until  shrinkage 
of  the  clot  has  loosened  its  hold  and  allowed  of  its  expulsion  from 
the  canal. 

Some  years  ago  I  happened  to  be  examining  with  the  cystoscope 
a  patient  who  had  suffered  from  profuse  hsematuria,  but  in  whom  the 
bleeding  had  ceased  abruptly  three  days  before.  I  was  able  to 
demonstrate  the  right  ureteral  opening  to  a  large  number  of  medical 
men.  Partially  extruded  from  that  orifice  and  plugging  it  could  be 
seen  a  long,  gray,  twisted  clot.  The  patient  himself  had  noticed  that 
the  reappearance  of  every  attack  had  been  heralded  or  had  been  ac- 
companied by  the  presence  of  a  long  cylindrical  black  or  grayish 
clot.  To  make  the  chain  of  evidence  complete,  I  introduced  an  evacu- 
ating catheter,  directed  its  eye  toward  the  right  ureter,  and  applied 
the  aspirating  ball ;  then  with  a  slight  suction  movement  I  swept  the 
clot  into  the  bottle.  On  immediately  reinserting  the  cystoscope, 
streams  of  scarlet  blood  could  be  seen  jetting  out  of  the  uncorked  ori- 
fice. I  removed  the  kidney  then  and  there,  and  found  a  small  carci- 
nomatous growth  ulcerating  into  the  pelvis. 

But  clots  forming  in  the  ureter  are  sometimes  like  thin  red  fishing- 
worms,  and  concerning  these  there  must  be  some  uncertainty,  for 
similar  clots,  though  perhaps  flatter  and  thicker,  are  moulded  in  the 
prostatic  urethra. 

Axiom  ii. :  "  Large,  irregular-edged,  scarlet  clots  are  derived  from 
a  bladder  source  if  traumatism  of  the  kidney  and  renal  tumor  are 
excluded." 

*  I  have  several  times  had  such  a  specimen  sent  me  by  medical  men  with  an  inquiry 
if  it  was  a  Strongylus  Gigas  worm.  In  the  light  of  such  a  request  it  is  suspicious 
to  see  quoted  in  the  French  literature  tlie  case  of  a  patient  "  who  passed  a  Strongy- 
lus  Gigas  from  an  enlarged  kidney  which  subsequently  became  carcinomatous.  " 


532  FENWICK — DISEASES   OF  THE  URINE. 

I  have  seen  enormous  clots  of  scarlet  hue  evacuated  in  cases  of 
renal  growth,  so  large  indeed  as  to  make  one  wonder  that  the  urethra 
allowed  of  their  transit,  but  these  cases  are  uncommon,  and  usually 
the  clots  from  carcinoma  of  the  kidney  are  much  darker.  They  are 
often  described  by  those  of  the  commoner  class  as  being  like  blocks 
of  bullock's  liver. 

Gelatination  of  Urine. — The  late  Professor  Ultzmann '  called  at- 
tention to  a  condition  of  urine  which  he  termed  Jibrinuria,  and  which 
he  considered  an  important  diagnostic  feature  in  villous  growths  of 
the  bladder.  The  urine,  on  being  passed,  is  of  a  reddish-yellow 
color;  it  coagulates  almost  immediately  into  a  jelly-like  mass.  Such 
urine  does  not  contain  much  blood,  as  shown  by  its  color ;  hence  the 
coagulum  is  not  in  proportion  to  the  quantity  of  blood  present  in  the 
urine. 

XTltzmann's  theory  of  the  production  of  fibrinuria  is  that  the  spas- 
modic contraction  of  the  bladder  checks  the  blood  returning  from  the 
villi,  and  the  vascular  loops,  therefore,  become  extremely  turgid.  If 
the  blood  pressure  is  very  great  the  vessels  rupture  and  hemorrhage 
ensues ;  if  the  tension  is  not  sufficient  to  cause  rupture  of  the  vessels 
a  transudation  of  jjlasma  occurs,  and  its  fibrin  coagulates  on  the 
emission  of  the  urine.  This  increased  vascular  tension  also  accounts 
for  the  presence  of  more  albumin  in  the  urine  than  would  correspond 
to  the  quantity  of  blood  and  pus  present. 

Ultzmann  gives  three  cases  in  which  he  had  observed  this  symptom. 
Willis  ("Urinary  Diseases  and  their  Treatment, "  p.  169, 1838)  men- 
tioned a  case :  "  The  urine  gelatinized  in  the  utensil,  and  when  viewed 
by  transmitted  light  was  of  a  pale  red-currant- jelly  color."  This 
condition  must  be  rare.  I  have  not  met  with  a  single  well-marked 
instance  in  150  cases  of  vesical  growth. 

(3)  The  Time  at  ivJiich  the  Blood  Appears  in  the  Stream. — Axiom: 
"  Blood  appearing  toward  or  at  the  finish  of  clear  urination  denotes 
a  vesical  or  a  prostatic  origin." 

This  is  a  rule  which  can  be  safely  relied  upon.  The  cause  of  its 
production  is  obvious.  The  vesical  muscles  form  contractile  jjlanes 
which  are  situated  between  two  vascular  surfaces,  an  external  sub- 
peritoneal layer  and  an  internal  mucous  membrane.  The  external 
subperitoneal  venous  nets,  which  empty  themselves  into  the  internal 
iliac  veins,  receive  the  blood  from  the  internal  mucous  membrane 
mesh,  by  means  of  vessels  piercing  the  muscle  planes.  When  the 
muscle  planes  contract,  the  external  venous  nets  empty  themselves, 
and  are  prevented  by  means  of  valves,  from  refilling  by  regurgita- 
tion," but  the  internal  meshes  become  more  turgid  with  blood  as  the 
contraction  increases,  for  their  efflux  trunks  are  compressed  by  the 


DIAGNOSIS  OP  URmARY  HEMORRHAGE.  533 

muscles  througli  which  they  pass  on  their  way  to  join  the  external 
nets.  The  vessels  underlying  or  abutting  on  any  breach  of  surface 
such  as  an  ulceration,  or  any  thin-walled  vessels  such  as  those  which 
form  the  basis  of  the  structure  of  villous  growths,  will,  therefore,  have 
dangerous  venous  pressure  placed  upon  them  on  contraction  of  the 
bladder.  If  to  the  force  of  an  ordinary  expulsive  effort  is  added  the 
extra  stress  of  straining,  the  rupture  of  a  congested,  weakened,  or 
thin-walled  surface  mesh  is  easily  produced,  and  a  little  blood  is  ex- 
pelled after  or  toward  the  end  of  the  vesical  contraction. 

Occasionally  cases  will  be  encountered  in  which  blood  issues  first 
and  is  followed  by  clear  or  clearer  urine.  Care  should  be  exercised 
in  accounting  for  this  somewhat  unusual  occurrence.  In  most  cases 
the  blood  will  be  in  the  form  either  of  a  darkish  clot  or  of  dark  fluid 
blood,  and  the  reason  why  it  precedes  the  stream  of  clear  urine  is 
because  it  has  dropped  to  the  orifice  of  the  bladder  just  as  it  would 
settle  down  in  a  conical  urine-glass.  It  is,  therefore,  shot  out  first. 
It  is  no  certain  sign,  however,  of  prostatic  or  urethral  origin.  In  the 
majority  of  cases  it  is  from  the  bladder  or  from  a  renal  source. 
Should  brightish  fresh  blood  issue  at  the  commencement  of  the 
stream  the  origin  is  probably  urethral. 

A  gentleman,  aged  fifty-two,  was  sent  to  me  by  Dr.  Alexander  of 
Paignton,  in  the  hope  that  the  clots  which  he  was  passing  originated 
in  the  urethra.  They  were  moulded  like  iirethral  clots,  and  preceded 
the  stream.  There  was  slight  smarting  three  inches  from  the  meatus 
when  they  were  passed.  On  examination  a  largish  right  renal  growth 
was  discovered,  which  was  removed.  Doubtless  the  clots  which  col- 
lected in  the  renal  pelvis  were  gradually  pressed  down  the  ureter, 
finally  dropped  on  to  the  lowest  part  of  the  bladder,  and  were  swept 
away  in  the  first  part  of  the  outrush. 

Axiom :  "  Blood  issuing  from  the  meatus  independently  of  mictu- 
rition is  from  an  urethral  source." 

(4)  On  the  Subsidence  of  the  Blood  in  a  Conical  Glass. — R.  v. 
Jaksch  asserts  that  "  when  blood-cells  are  intimately  mixed  with  the 
urine  in  such  a  way  that,  though  present  in  large  quantity  and  deeply 
tinging  the  fluid,  they  do  not  form  a  sediment  after  many  hours' 
standing,  it  may  be  inferred  that  the  hemorrhage  took  place  in  the 
substance  of  the  kidney  or  in  the  renal  pelvis  or  ureters.  If,  under 
these  circumstances,  they  are  seen  with  the  microscope  to  be  pro- 
foundly altered,  having  lost  their  coloring  matter  and  presenting 
the  appearance  of  pale  yellow  rings,  the  further  conclusion  results 
that  the  blood  has  been  effused  from  the  kidney  itself,  and  the  symp- 
tom points  to  acute  nephritis  or  to  a  fresh  exacerbation  in  the  course 
of  chronic  nephritis. " 


534  FENWICK — DISEASES  OP  THE  URINE. 

Qualification:  Dr.  James  Tyson^  has  pointed  out  tliat  in  some 
cases  of  alkaline  urine  a  true  lisematuria  may  in  the  course  of  a  few 
hours  become  a  hsemoglobinuria  from  the  solution  or  disintegration 
of  the  red  blood  discs.  This  especially  takes  place  in  warm  weather. 
In  fact  Dr.  Tyson  has  known  urine  to  be  sent  from  southern  parts 
of  the  United  States,  which  when  shipped  contained  blood  corpuscles, 
but  in  which  when  received  in  Philadelphia  no  blood  discs  were  dis- 
coverable, only  large  amounts  of  blood-coloring  matter.  Such  a  con- 
dition would  render  v.  Jaksch's  rule  inaccurate. 

(5)  The  Belationship  between  tJie  Hcemoglobin  and  ATbumin. — 
Newman  has  shown  that  the  relationship  between  the  quantity  of 
haemoglobin  and  the  amount  of  albumin  in  the  urine  aids  greatly  in 
determining  the  seat  of  the  hemorrhage.  "  Thus  if  the  quantity  of 
haemoglobin  and  the  amount  of  albumin  determined  by  one  or  other 
of  the  recognized  processes  be  compared,  and  if  the  ratio  of  albumin 
to  haemoglobin  is  as  1  to  1.6,  then  it  may  be  concluded,"  says  Dr. 
Newman,  "that  the  appearance  of  albumin  is  entirely  due  to  the 
presence  of  blood;  but  if  the  quantity  of  albumin  is  much  increased 
beyond  the  proportion  just  mentioned,  the  indication  is  in  favor 
not  only  of  an  independent  albuminuria,  but  also  points  to  a  renal 
affection  as  the  cause  of  the  haematuria." 

(6)  Absorption  Test. — It  has  been  pointed  out  by  Ultzmann 
that  if  potassium  iodide  solution  is  injected  into  the  bladder,  it  is 
absorbed  if  any  abraded  surface  exists  and  can  be  detected  in  the 
saliva.  If  there  is  no  absorption  of  the  iodide,  it  can  be  inferred  that 
the  continuity  of  the  vesical,  mucous  membrane  is  intact. 

(7)  3Iicroscopy . — Blood  Casts:  The  presence  of  blood  casts  gives 
an  accurate  clue  to  the  origin  of  the  hemorrhage.  I  have  met  with  one 
case  of  severe  paraffin  burn  of  the  whole  body  in  which  the  patient 
passed  an  ounce  of  perfect  blood  cylinders  in  eight  ounces  of  secre- 
tion. The  cylinders  fell  at  once  to  the  bottom  of  the  conical  glass, 
and  presented  a  very  curious  appearance.  Death  took  place  in  a 
few  hours.  The  kidneys  were  turgid  with  blood  and  in  the  first 
stage  of  nephritis. 

Granular  Casts :  The  presence  of  granular  casts  in  the  urine  points 
in  most  instances  to  the  kidneys  as  the  source  of  the  hemorrhage. 

Growth:  It  is  not  an  uncommon  event  (recorded  in  19.3  per  cent, 
of  vesical  tumors)  for  the  patient  to  pass  visible  pieces  of  growth. 
I  have  met  with  fragments  which  varied  in  size  from  a  pea  to  a 
necrosed  mass  haK  the  length  of  the  little  finger.  Probably  in  most 
cases  microscopic  pieces  are  passed,  chiefly  consisting  of  the  villous 
processes.  These,  though  they  indicate  a  tumor,  do  not  definitely 
settle  the  character  of  the  growth. 


DIAGNOSIS  OF  URINARY  HEMORRHAGE.  535 

Forty -one  per  cent,  of  vesical  carcinomata  liave  a  surface-covering 
of  villous  processes,  while  in  half  the  cases  of  villous  cancer  villous 
papillomatous  growths  of  the  pure  type  apparently  produced  by  irri- 
tation coexist  in  the  bladder  with  the  carcinoma ;  17  out  of  46  cases 
of  single  carcinomatous  tumors  had  villous  coverings;  18  out  of 
36  multiple  carcinomatous  tumors  had  villous  surfaces.  Pure  vil- 
lous tufts  coexisted  in  one-sixth  of  the  cases  of  sarcomatous  tumors, 
and  one-fourth  of  the  epitheliomata  (Author,  Pathological  Society 
Transactions,  1888,  Vol.  XXXIX.,  p.  180,  and  Jacksonian  Prize 
Essay,  p.  144). 

Eggs  of  the  Bilharzia  Hgematobia  (Distoma  Hgematobium) : 
The  yellowish,  well-defined  egg,  furnished  with  its  terminal  or  lateral 
spine,  is  readily  recognizable. 

B.     Examination  of  the  Patient  for  the  Source  of  Hcemafuria. 

1.  Physical  Examination. — The  physician  will  do  well  to  make  a 
thorough  examination  of  all  accessible  parts  of  the  urinary  tract 
before  instituting  any  instrumental  exploration  as  to  the  cause  of 
hsematuria.  I  hold  very  strongly  that  it  is  culpable  for  instrumenta- 
tion of  any  form  to  be  carried  out  before  all  other  methods  of  research 
are  exhausted.  My  reasons  for  this  hard  and  fast  rule  will  be  given 
subsequently. 

Kidneys. 

The  renal  region  must  be  palpated  to  ascertain  the  existence  of  any 
undue  tenderness,  enlargement,  or  displacement  of  the  kidneys.  Is- 
rael's method  of  paljjation  is  a  very  satisfactory  one.  A  line  parallel 
with  the  middle  line  of  the  abdomen  is  drawn  from  the  middle  of  Pou- 
part's  ligament  to  the  margin  of  the  ribs.  The  finger-tips,  placed  two 
finger-breadths  below  the  margin  of  the  ribs  and  upon  this  line,  are 
directly  over  the  lower  extremity  of  a  kidney  in  place.  In  order  to 
feel  this  kidney  we  must  avoid  poking  with  eager  hooked  fingers,  or 
the  abdominal  muscles  will  contract  in  resentment.  The  tips  of  the 
straight  extended  fingers  are  placed  upon  the  point  indicated  while 
the  patient  lies  supine,  with  flexed  legs,  upon  a  hard  bed  or  table. 
The  other  hand  now  lifts  the  loin  gently  toward  the  opposed  fingers. 
At  each  expiration  which  the  patient  makes  the  fingers  upon  the 
abdomen  are  pressed  a  little  farther  toward  the  kidney,  and  it  is  not 
long  before  the  fingers  easily  recognize  the  object  sought  for.  If  the 
patient  now  takes  a  full  breath,  a  wandering  kidney  will  be  forced  far 
under  the  finger-tips.  I  believe  every  renal  tumor  is  one-third  larger 
than  we  think  it  is. 


536  FENWICK — DISEASES  OF  TSE  UKINE. 

Tenderness. — Rough  palpation  elicits  varying  degrees  of  pain  in 
any  kidney  which  has  some  portion  of  its  substance  inflamed.  Simple 
or  ulcerating  pyelitis,  chronic  abscess  of  the  kidney,  inflamed  cyst, 
acute  suppurative  nephritis, — in  all  these,  tenderness  can  be  elicited  by 
deep  pressure.  It  is  a  mistake,  then,  to  consider  that  pain  can  be 
evoked  by  palpation  only  when  stone  is  present.  I  will  admit  that,  in 
most  cases  of  long-standing  of  stone  imbedded  in  the  cortex  or  a  deep 
calyx,  or  in  cases  of  stone  in  the  pelvis  large  enough  to  press  apart  the 
walls  of  this  cavity,  there  is  a  characteristic  stabbing  pain  on  percus- 
sion over  the  front  of  the  kidnej^,  but  this  "  stab"  is  not  elicited  in  all 
cases  of  renal  calculus  by  percussion.  Its  absence,  therefore,  does 
not  exclude  stone.  The  inflamed  kidney  always  tends  to  be  drawn 
upward  under  the  ribs.  This  change  of  position  must  be  allowed  for 
in  palpation  and  percussion. 

Enlargement. — In  unusually  thin  people  the  tail  or  lower  end  of 
the  kidney  can  be  easily  examined.  But  a  kidney  which  is  not 
markedly  movable  and  which  can  be  readily  felt  in  its  entire  extent 
by  the  palpating  fingers  is  abnormally  large.  It  may  not  be  diseased 
but  merely  hypertrophic,  for  it  has  often  been  demonstrated  that  when 
one  kidney  is  atrophied  the  fellow-gland  has  become  correspondingly 
enlarged  in  doing  double  duty.  Perceptible  enlargement  of  the  non- 
mobile  kidney  without  a  history  of  a  previous  traumatism  to  the 
opposite  loin,  coexisting  with  blood  in  the  urine,  is  a  condition 
which  should  at  once  arrest  attention. 

The  questions  raised  by  enlargement  are :  Is  it  a  tough  kidney 
irritated  by  the  presence  of  a  large  stone?  Is  intermittent  hydro- 
nephrosis present?  Are  tubercular  changes  in  progress?  Is  it  a 
growth;  a  carcinoma  or  sarcoma;  or  is  the  kidney  merely  mobile? 

It  is  noteworthy  that  calculi,  even  those  of  large  size,  sometimes 
remain  latent  in  the  kidney  except  for  an  occasional  hsematuria.  I 
believe  this  mostly  happens  in  the  young  adult.  Primary  chronic 
tubercular  disease  of  the  kidney  occurs  usually  in  patients  over  twenty 
years  of  age  with  a  family  history  of  phthisis.  The  kidney,  before 
perinephritis  has  set  in,  is  hard,  rounded,  smooth,  usually  mov- 
able, and  very  tender.  It  rarely,  in  my  experience,  reaches  the 
size  of  a  large  closed  fist  without  inducing  inflammatory  adhesion 
and  thickening  around  it.  This  fixes  the  kidney  and  draws  it 
slightly  upward  under  the  ribs,  whence  it  is  pushed  downward  in  the 
third  and  last  stage  by  abscess  accumulation — a  grade  marked  by 
elevated  temperature  and  other  signs. 

Sarcoma  of  the  child's  kidney  is  too  rapid  in  its  growth  and  too 
characteristic  to  require  notice.  The  uninflamed  sarcomatous  and 
carcinomatous  tumors  of  the  kidney  (in  patients  over  forty-five  years 


tolAGKOSIS   OF  URINARY  BEMORRHAGE.  537 

of  age)  are  usually  large,  smooth,  insensitive,  and  movable  long  after 
the  hemorrhage  has  appeared,  unless  an  injury  has  started  the  hsema 
turia  in  the  earlier  stages. 

It  sometimes  happens  that  a  kidney  is  so  freely  movable  behind 
the  peritoneum  that  its  excursions  may  occasionally  kink  the  ureter 
and  produce  intermittent  hydronephrosis.  When  the  attack  conse- 
quent upon  the  backward  pressure  subsides  by  the  straigntening  of 
the  ureter,  blood  may  appear  in  the  urine. 

Ureters. 

The  examination  is  to  be  carried  along  the  track  of  the  ureters 
by  deep  palpation  in  order  to  ascertain  if  tenderness  exists  along 
the  length  of  these  channels  or  in  definite  patches.  It  is  espe- 
cially necessary  to  make  deep  pressure  over  the  point  where  the 
ureter  turns  over  the  brim  of  the  pelvis,  for  it  is  here  that  calculi 
sometimes  lodge  in  their  transit,  and  they  may  produce  considerable 
hemorrhage  by  ulceration.  *  Moreover,  a  diseased  ureter  is  best  ex- 
amined for  tenderness  against  a  bony  background.  The  lower  sec- 
tion of  the  ureters  should  now  be  examined  per  rectum  or  per  vaginam 
in  the  knee-and-elbow  position.  This  is  best  done  after  the  bladder 
has  been  voluntarily  emptied.  Calculi  have  been  discovered  in  the 
female  by  this  means  and  removed  by  an  incision  through  the  vagi- 
nal roof;  and  in  the  male  the  opportunity  is  now  afforded  of  examin- 
ing the  base  of  the  prostate  and  vesiculse  seminales  for  enlargement. 

Base  of  the  Bladder. 

Any  hardening  or  thickening  in  the  bladder  base  can  be  de- 
tected by  gentle  examination  with  the  finger.  I  consider  it  very 
necessary  to  insist  upon  the  caution  that  all  digital  examination 
must  he  gentle,  rapid,  and  purposive.  I  have  several  times  witnessed 
a  slight  vesical  bleeding  increased  to  grave  and  uncontrollable  hem- 
orrhage by  rough  examination  per  rectum.  Probably  the  undue 
finger  pressure  has  split  the  thick  but  friable  structure  of  the  base  of 
the  growth  and  laid  open  its  vascular  channels.  I  have  seen  cases 
of  large  encapsulated  vesical  calculus  pass  through  very  dangerous 
renal  reaction  with  high  temperature  after  prolonged  rectal  examina- 
tion. I  have,  moreover,  known  vesical  and  renal  tubercle  decidedly 
worse  for  energetic  examination  with  the  fingers.  The  most  common 
cause  of  thickening  after  the  age  of  forty-five  is  carcinomatous  infiltra- 

*  I  have  seen  very  severe  hemorrhage  from  this  cause,  necessitating  nephrectomy. 
The  calculus  was  felt  in  the  uretor  nt  tlin  pelvic  brim.     The  patient  (a  lady)  did  well. 


538  FENWICK — DISEASES  OF  THE  UKINE. 

tion.  This  is  usually  felt  at  one  or  other  side  of  the  base  in  the  earlier 
stage  because  the  growth  generally  commences  near  one  or  other 
.ureter.  It  is  almost  conclusive  if  examination  of  a  dense  hard 
plaque  by  the  rectum  is  followed  by  a  sharp  hemorrhage  from  the  blad- 
der, testifying  that  the  carcinomatous  surface  toward  the  bladder 
has  been  split  by  the  pressure  of  the  finger. 

Two  other  forms  of  definite  hardness  of  the  bladder  base  may  be 
encountered,  one  localized,  the  other  diffused.  The  former  is  due  to 
encysted  stone,  in  which  the  finger  feels  the  round  stone  through  the 
thinnest  of  thin  partitions,  the  walls  of  the  sac ;  and  the  latter — the 
diffuse  hardness  which  coexists  with  tubercular  testicle — is  due  to  one 
or  other  of  the  vesiculse  seminales  (rarely  both)  being  transformed 
into  a  long,  flat,  hard  cake  of  tubercular  material. 

Prostate. 

The  prostate  should  be  mapped  out  with  the  finger  into  its 
two  lobes  and  the  intei'vening  sulcus.  Dense  localized  hardness  of 
the  adult  prostate  is  due  to  the  presence  either  of  tubercular  deposit 
or  of  stones  which  have  replaced  the  prostatic  tissue.  There  is  rarely 
much  difficulty  in  distinguishing  between  the  two.  The  tubercular 
deposit  occurs  most  often  as  a  small  projection  the  size  of  a  monkey 
nut  situated  in  one  or  other  of  the  lateral  lobes.  The  corresponding 
epididymis  in  many  cases  is  affected  previously.  It  is  stated  that 
the  prostate  lobes  are  shotty  in  cases  of  tubercle  of  this  organ.  The 
many-small-shot-like  feel  is  much  rarer  than  the  defined  mass. 

Prostatic  calculi  which  can  be  felt  per  rectum  are  always  multiple 
and  can  be  made  usually  to  grate  on  one  another.  They  are,  more- 
over, much  harder  than  the  tubercular  deposit. 

At  or  about  the  age  of  fiftj"  the  prostate  may  take  on  carcinoma- 
tous degeneration  or  enlarge  from  senile  changes  toward  the  rectum 
or  bladder  or  both.  Carcinoma  is  usually  detected  at  once  by  the 
irregular,  dense,  diffused  stone-like  feel  of  the  gland ;  senile  changes 
invariably  exhibit  a  uniform  enlargement  and  more  or  less  elastic  re- 
sistance to  the  finger.  It  should  be  remembered  that  a  full  bladder 
in  the  stooping  posture  flattens  the  prostate  and  gives  it  a  fictitious 
hardness. 

It  is  wise  at  this  time  to  examine  the  bladder  bimanually,  the  pa- 
tient being  still  in  the  knee-and-elbow  position ;  the  fingers  of  the  left 
hand  are  placed  on  the  pubes  and  an  attempt  is  made  to  approxi- 
mate them  to  the  finger  in  the  rectum  or  vagina.  By  this  means  any 
pronounced  hard  growth  in  the  bladder  from  the  lateral  wall  or  apex 
may  be  recognized. 


DIAGNOSIS  OF  UEINARY  HEMORRHAGE.  539 

Testicle. 

The  vasa  deferentia  are  to  be  searched  for  the  bead-like  deposit  of 
tubercle,  and  the  epididymis  (the  globus  minor  especially)  should  be 
examined  for  a  similar  infiltration. 

Any  sudden  onset  late  in  life  (after  forty-five)  of  a  varicocele  is 
to  be  regarded  with  suspicion  as  indicating  malignant  disease  of  the 
corresponding  kidney. 

Instrumental  Examination. — Various  methods  have  been  devised 
to  ascertain  whether  the  blood  has  originated  in  the  kidney  or  in 
the  bladder,  such  as  those  suggested  by  Pawlik,  Silbermann,  Polk, 
Tuchmann,  Gliick,  Hurry  Fenwick.  Most  of  these  procedures  can 
only  be  employed  by  their  originators.  Since  the  introduction  of 
electric  cystoscopy  those  which  were  accounted  as  serdceable  in 
the  male  have  been  relegated  to  obscurity.  Any  instrumental  ex- 
ploration of  the  bladder  by  means  of  the  catheter,  sound,  lithotrite* 
(Thompson) ,  calculus  aspirator  (Chismore  ') ,  or  sharp  curved  curette 
(Kuster),  is,  I  am  sure,  unsurgical  and  unsafe  in  all  cases  of  hcema- 
turia  unaccompanied  hy  other  symptoms  of  urinary  disorder.  If  any 
instrumental  examination  is  necessary  in  this  class  of  cases,  let  it  be 
a  gentle,  purposive,  educated  cystoscopy,  and  let  the  examination  be 
made  with  full  leave  to  proceed  at  once  to  any  operation  which  the 
electric  light  may  indicate  as  being  necessary.  I  would  emphasize 
this  statement  by  asserting  that  I  recognize  no  disease  of  the  urinary 
organs  in  which  bleeding  is  a  prominent  symptom  which  necessi- 
tates the  routine  use  of  either  sound  or  catheter  for  its  detection,  and 
I  know  of  no  urinary  disease  which  may  not  be  materially  aggravated 
by  the  employment  of  these  instruments.  I  speak  thus  strongly  be- 
cause the  existence  of  blood  in  the  urine  suggests  at  once  to  the 
mind  of  most  practitioners  the  use  of  the  calculus  sound.  Now  this 
instrument  is  useful  only  in  a  very  limited  class  of  cases,  viz.,  that  of 
stone  in  the  bladder ;  and,  as  I  shall  point  out  immediately,  hsema- 
turia  is  very  rarely  the  sole  symptom  evoked  by  a  calculus.     Even 


*  Sir  Henry  Thompson  suggests  pulling  pieces  of  growth  oflf  the  main  mass  by 
means  of  a  light  lithotrite  ("  Vesical  Tumors,  "  British  Medical  Journal,  1890,  ii. , 
p.  332,  foot-note) .  If  the  microscopy  of  pieces  of  growth  removed  by  means  of 
operation  is  a  tragic  farce  as  regards  the  real  character  of  the  growth,  still  less  will 
the  true  nature  of  the  growth  be  shown  by  a  microscopic  examination  of  these  villous 
tags.  Cf.  Case  8,  Sir  H.  Thompson,  "Tumors  of  Bladder,"  1884,  p.  103.  The 
growth,  "bitten"  or  "chewed"  off  at  the  operation,  was  reported  to  be  "composed 
of  normal  bladder  tissue,  fimbriated  papilla)  abundant ;  no  structure  resembling 
malignant  growth  was  found,  "  but  the  patient  "died  two  months  after  with  second- 
ary malignant  growth  in  thigh.  " 


540  FENWICK — DISEASES   O-F  THE   URINE. 

tlien  sounding  had  better  not  be  done  until  all  preparations  for  simul- 
taneous litholapaxy  have  been  completed. 

My  reasons  for  opposing  all  forms  of  instrumentation  in  symp- 
tomless hsematuria  are  as  follows :  I  have  known  the  use  of  the  cathe- 
ter and  washing  to  cause  death  in  three  cases  of  renal  carcinoma 
in  the  course  of  a  single  week.  I  have  seen  it  induce  fatal  suppres- 
sion in  renal  tuberculosis ;  dangerous  pyelitis  and  cystitis  in  cases  of 
vesical  growth ;  I  have  known  it  dangerously  aggravate  cases  of  gran- 
ular nephritis,  cause  acute  renal  abscess  in  vesical  tubercle,  and  pro- 
duce death  in  cases  of  vesical  stone  coexisting  with  advanced  but 
unsuspected  renal  degeneration ;  I  have  known  of  deaths  from  sup- 
purative nephritis,  and  from  sloughing  of  vesical  tiimor;  and  I  have 
seen  retention  and  alarmingly  profuse  hemorrhages  follow  sounding 
in  cases  of  tumor  of  the  bladder  (severe  hemorrhage  following  upon 
gentle  sounding  jjoints  to  the  presence  of  a  new  growth)  — in  fact,  my 
note-books  are  interspersed  with  cases  in  which  instrumentation  in 
symptomless  hgematuria  has  brought  discredit  upon  the  practitioner 
and  disaster  upon  the  patient. 

It  is,  however,  quite  otherwise  in  those  cases  of  hsematuria  in 
which  symptoms  of  vesical  or  prostatic  disease,  pain,  frequency  of 
micturition,  and  obstruction  to  the  stream,  have  preceded  the  appear- 
ance of  the  blood.  In  these  cases  instrumental  exploration  is  often 
absolutely  necessary  for  a  differential  diagnosis,  and  if  employed  skil- 
fully and  judiciously  it  is  as  free  from  risk  as  is  any  instrumentation 
through  the  deep  urethra  of  males.  The  urethral  bougie  will  elimi- 
nate stricture,  the  sound  determines  the  presence  of  stone  and  the  in- 
travesical enlargement  of  the  senile  prostate,  while  the  catheter  estab- 
lishes at  once  the  presence  or  absence  of  residual  urine.  I  may 
remark,  incidentally,  that  the  risk  of  instrumentation  increases  after 
forty-five  years  of  age  with  every  year ;  that  more  danger  is  incurred 
in  town  dwellers  than  in  those  who  have  led  healthy  out-door  lives ; 
that  malaria  and  the  various  tropical  fevers  probably  leave  the  kidneys 
less  able  to  bear  any  sudden  stress  of  reflex  congestion. 

C.   Oritical  Examination  of  the  Symptoms. 

In  the  larger  proportion  of  cases  the  appearance  of  blood  in  the 
urine  is  heralded  by  symptoms  of  pain  or  uneasiness  in  the  kidneys, 
ureters,  bladder,  prostate,  or  urethra,  or  by  functional  disturbances  of 
the  bladder  such  as  obstruction  to  the  stream  or  frequency  of  micturi- 
tion. Such  symptoms  direct  the  practitioner's  attention  to  the  part 
and  permit  him  to  locate  the  probable  source  of  the  hemorrhage. 
This  is,  however,  not  always  so.     There  are  a  certain  number  of 


DIAGNOSIS   OF  URINARY   HEMORRHAGE.  541 

patients — the  minority — who  complain  of  no  other  symptom  beyond 
the  appearance  of  blood  in  the  urine,  and  who  assert  that  if  they  were 
blind  or  urinated  in  the  dark  they  would  believe  themselves  to  be 
in  perfect  health.  This  circumstance  allows  of  the  subject  of  hsema- 
turia  being  discussed  under  the  headings  of  Symptomless  Hsematuria 
and  Hsematuria  with  Symptoms,  and  to  establish  these  very  obvious 
classes  the  practitioner  must  tactfully  elicit  the  exact  character  of  the 
onset  symptoms. 

I  hold  that  an  accurate  history  of  the  character  of  the  onset  of 
the  urinary  symptoms  is  one  of  the  most  important  factors  in  shap- 
ing the  diagnosis  of  the  site  and  cause  of  the  bleeding. 

But  there  are  other  atoms  which  go  to  form  the  molecule  of  accu- 
rate diagnosis,  and  these  also  should  be  included  in  a  preliminary 
consideration  of  each  case.  The  age,  the  sex,  the  pre-existence  or 
coexistence  of  grave  constitutional  disorders,  the  exhibition  of 
drugs,  errors  in  diet,  the  occurrence  of  direct  or  indirect  violence,  all 
these,  though  in  themselves  of  but  slight  diagnostic  import,  are  fac- 
tors which  prove. of  value  in  forming  rapid  conclusions. 

Sex. — Hsematuria  is  uncommon  in  the  female.  When  it  occurs 
in  the  young  adult  before  marriage,  and  urethral  carbuncle  is  elimi- 
nated, vesical  ulceration  of  a  tubercular  tyi)e  ought  to  be  considered. 
If  it  occurs  after  marriage  and  before  the  age  of  forty,  a  careful  ex- 
amination of  the  uterus  should  be  made,  for  this  organ  is  often  at 
fault.  As  a  result  of  dragging  by  the  uterus  on  the  bladder  or  of  the 
extension  of  inJQammation  to  the  base  of  that  organ  cystitis  is  com- 
mon. The  bladder  is  frequently  affected  by  carcinoma  propagated 
from  the  uterus.  Vesical  stone  is  rare,  but  inflammatory  renal  mis- 
chief from  ascending  pyelitis  is  comparatively  frequent.  Males  are 
much  more  prone  to  hemorrhage  from  all  parts  of  the  urinary  tract. 
This  is  probably  due  to  their  greater  exposure  to  accidents  and  to 
the  sequelae  of  venereal  diseases.  Primary  growths  of  the  bladder 
occur  five  times  more  often  in  man  than  in  woman,  and  I  believe  the 
young  male  is  more  often  affected  than  the  female  with  tuberculosis 
and  renal  stone. 

Age. — Before  five  the  causes  of  hsematuria  are  more  commonly 
those  due  to  scorbutic  troubles  from  dietetic  errors ;  renal  concretions 
come  next,  while  sarcoma  of  the  kidney  and  myxosarcoma  of  the  blad- 
der are  very  rare. 

Between  puberty  and  twenty,  tubercle  of  the  bladder  and  renal 
stone  furnish  the  larger  proportion,  but  prostatic  congestions  due  to 
excessive  masturbation  or  venereal  indulgence  are  not  to  be  for- 
gotten. 

Between  twenty  and  thirty,  prostatic  congestions  due  to  gonorrhoea 


542  FENWICK — DISEASES   OF  THE  URINE. 

or  leucorrlioeal  -urethritis,  urinary  tuberculosis,  chrome  Bright' s  dis- 
ease, villous  papilloma,  and  vesical  stone  are  met  with. 

Between  thirty  and  forty,  stricture  (rare), and  vesical  papilloma.* 

After  forty,  vesical  papillary  growth  with  a  tendency  in  the  base 
to  become  carcinomatous. 

About  and  after  fifty,  renal  growth,  prostatic  hemorrhage,  vesical 
stone,  and  carcinoma  of  the  bladder  are  the  usual  causes  for  hsema- 
turia. 

Ch^ave  Coristitutioncd  Disorders. — Blood  in  the  urine  appears  in  the 
course  of  some  malignant  fevers,  such  as  measles,  small-pox,  typhus 
fever,  septicaemia,  or  after  cholera  (Prout).  The  appearance  of  blood 
under  these  circumstances  is  considered  as  a  very  grave  sign  indeed, 
but  of  the  renal  origin  and  cause  there  is  no  doubt.  It  is  also  not 
uncommon  in  malaria  and  scurvy.  Lastly,  evidence  is  slowly  collect- 
ing of  a  distinct  and  exhausting  renal  hemorrhage  which  occurs  in 
cases  of  the  hemorrhagic  diathesis. 

After  Certain,  Forms  of  Diet. — Certain  articles  of  diet  are  known 
to  produce  hsematuria  if  indulged  in  too  freely,  or  if  taken  by  per- 
sons of  gouty  habit,  or  by  those  who  have  a  special  idiosyncrasy. 
Thus  the  common  or  garden  rhubarb"  may  produce  a  sharp  attack  of 
hsematuria,  with  frequent  and  painful  micturition,  more  or  less  pain  in 
the  loins,  and  general  indisposition.  The  blood  emanates  doubtless 
from  the  kidneys  in  these  cases.  Hard  drinking-water,  supplying  the 
lime  for  the  oxalic  acid  of  the  rhubarb  to  combine  with  and  form  oxa- 
late of  lime,  is  suggested  by  Dr.  O'Neill  as  being  a  necessary  factor. 

Some  fruits,  such  as  gooseberries,  unripe  apples,  and  certain 
species  of  strawberries,  are  credited  with  the  same  powers. 

Although  asparagus  is  known  as  a  diuretic,''  it  is  not,  I  believe, 
generally  supposed  to  induce  hsematuria.  Mr.  Reginald  Harrison* 
has,  however,  mentioned  the  occurrence  of  two  cases  of  this  kind  in 
his  practice. 

Other  vegetables  and  some  fruits  f  color  the  urine  like  blood,  but 
there  is  deficient  evidence  as  to  whether  they  actually  cause  bleeding. 

*  It  is  especially  as  regards  vesical  growth  that  the  age  is  a  valuable  indication. 

Thus  for  villous  papilloma  in  25  cases,  the  age  in  decades  and  the  cases  met  with 
were  as  follows  :  From  20  to  30,  3  cases  ;  30  to  40,  5  cases ;  40  to  50,  10  cases ;  50 
to  60,  6  cases  ;  60  to  70,  1  case — 25  cases. 

The  age  for  carcinoma  in  50  cases  :  32  to  39,  3  cases  ;  40  to  50,  7  cases ;  50  to  60, 
25  cases ;  60  to  70,  12  cases  ;  71  to  87,  3  cases — 50  cases. 

f  Beetroot :  "  Desault  relates  the  case  of  one  who  noted  his  morning  urine  was  of 
a  bright  blood-red  color.  He  consulted  M.  Koux.  It  was  found  that  he  eat  red 
beetroot  every  night  for  supper.  "  Logwood  and  madder  have  the  same  effect.  The 
prickly  pear  [Cactus  opimtia)  :  "When  the  Spaniards  first  took  America  many  of 
them  were  alarmed  by  observing  that  they  were  passing  what  they  supposed  was 


DIAGNOSIS   OP  URINAEY  HEMORRHAGE.  643 

After  Exhibition  of  Certain  Drugs.  * — Cantharides  and  turpentine 
are  the  two  chief  drugs  which  excite  hasmaturia.  They  cause  so 
much  renal  or  vesical  congestion  as  to  produce  the  escape  of  blood. 
The  former,  being  a  constituent  of  certain  quack  aphrodisiac  medi- 
cines, is  not  an  uncommon  evoker  of  hsematuria.  Spanish-fly  blis- 
ters produce  similar  results  in  patients  who  are  sensitive  to  the  use 
of  cantharides.  Mr.  Shalford  Walker  brought  before  the  notice  of 
the  Liverpool  Medical  Institute  in  1866  the  history  of  a  whole  crew 
of  a  ship  carrying  a  cargo  of  turpentine  being  affected  during  the 
voyage  with  hsematuria,  and  in  one  case  a  fatal  result  followed.  Mr. 
Harrison  suggested  that  this  was  due  to  inhalation. 

Diagnostic  Significance  of  Hcematuria  following  Slight  Indirect  Vio- 
lence. 

The  hsematuria  of  injury  does  not  require  notice.  The  injury  is 
direct,  the  history  of  the  blow  is  generally  obtainable,  and  the  locality 
is  usually  obvious,  but  careful  examination  should  elicit  from  the 
patient  facts  concerning  the  influence  of  slight  indirect  violence  upon 
the  production  of  a  spontaneous  hsematuria. 

If  a  slight  indirect  traumatism,  such  as  a  fall  on  the  buttock,  has 
produced  in  a  youth  or  young  adult  a  symptomless  renal  hsematuria, 
which  continues  or  intermits,  it  is  probable  that  some  pre-existing 
disease  such  as  latent  renal  stone  or  chronic  Bright 's  disease  was 
present,  and  is  now  responsible  for  the  obstinate  persistency  of  the 
bleeding.  In  these  cases  the  urine  may  reveal  traces  of  the  disorder 
in  the  shape  of  crystals  or  of  casts,  low  specific  gravity,  and  albumin. 

In  patients  over  forty  (an  arbitrary  age  depending  upon  statistics) , 
with  unsuspected  softish  malignant  growth  of  the  urinary  tract,  it  is 
often  a  slight  strain  which  appears  to  be  the  cause  for  the  first  attack 
of  the  hemorrhage.  Some  affirm  that  they  feel  or  hear  something 
"  snap"  or  "  give  way"  in  making  some  slight  exertion,  such  as  lifting 
an  article  of  furniture.  In  six  of  seventeen  cases  of  malignant  disease 
of  the  kidney  which  have  been  under  my  observation,  some  slight  in- 
direct violence  had  obviously  induced  the  bleeding.     In  one-third  of 

bloody  urine.  It  proved  to  be  due  to  the  liberal  use  of  the  prickly  pear. "  Dr. 
Hennen  ("Military  Surgery")  quotes  from  Ellicot's  Journal  of  his  "Travels  for  De- 
termining the  Boundary  of  the  United  States  : "  "  People  ate  very  plentifully  of  this 
substance  (prickly  pear)  at  an  island  of  the  Mississippi  (Kayoani) ,  and  were  not  a 
little  surprised  the  next  morning  at  finding  their  urine  appear  as  if  it  had  been  highly 
tinged  with  cochineal.     No  inconvenience  followed.  "^ 

*  Rhubarb  and  senna  in  alkaline  urine  impart  a  red  coloration  to  the  urine.  It 
is  removed  by  adding  acid,  and  returns  on  overcoming  the  acid  with  alkali.  Analgen 
colors  some  urines  a  cherry-red. 


544  FENWICK — DISEASES  OF  THE  URINE. 

the  cases  in  my  list  of  soft  malignant  vesical  growth,  the  initial  hem- 
orrhage had  apparently  some  direct  relation  to  a  slight  indirect  trau- 
matism. In  two  of  the  fifteen  cases  of  carcinoma  of  the  prostate  the 
bleeding  followed  immediately  on  indirect  violence.  The  small  num- 
ber in  the  latter  group  probably  depends  on  capsular  protection. 

Should,  therefore,  a  light  strain  or  a  decided  extra  exertion  be 
immediately  or  almost  immediately  followed  in  an  adult  over  forty  by 
a  smart  attack  of  hemorrhage,  a  friable  pre-existing  growth  should 
be  suspected  to  exist.  It  might  be  argued  that  the  slight  traumatism 
has  been  followed  by  a  new  growth ;  and  that  it  stands  to  the  growth 
in  the  relation  of  cause  and  effect.  Not  so.  Though  it  is  beside  the 
question  before  us,  I  msbj  remind  the  reader  that  the  cystoscope  has 
taught  us  that  soft  malignant  tumor  of  the  bladder  may  grow  latently, 
unsuspected  by  either  the  practitioner  or  patient,  and  that  cases  have 
been  examined  within  a  week  or  so  of  the  onset  of  hsematuria  and  a 
large  growth  then  discovered.  Hence  the  onset  of  hsematuria  does 
not  herald  the  birth  of  a  growth,  but  usually  denotes  a  tear  or  degen- 
erative change  in  the  surface  of  one  already  formed. 

Benign  growths  do  not  seem  to  be  so  often  affected  in  this  way, 
though  when  they  have  attained  a  large  size  they  will  often  bleed 
upon  some  extra  exertion  being  taken  by  the  patient. 

I  account  for  this  difference  in  the  behavior  of  malignant  and  non- 
malignant  tumors  when  roughly  shaken,  by  the  structural  differences 
of  the  stalk  or  base  of  these  two  varieties  of  growth,  that  of  the 
benign  type  being  less  rigid  and  less  friable  than  the  malignant — for 
it  is  composed  of  tissue  more  approaching  the  normal  in  character. 
I  would  suggest  that  the  surface  of  a  purely  benign  growth,  e.g.,  when 
covered  by  villous  processes,  is  much  less  damaged  by  the  succussions 
of  the  water  in  the  bladder  than  is  the  easily  tearable  neoplastic  base 
and  surface  of  a  carcinomatous  tumor,  for  the  latter  is  soldered  on  to 
the  waU,  and  its  attachment  has  to  bear  the  strain  of  the  stretching  of 
the  adjoining  muscle  as  it  yields  before  the  momentum  of  the  urine 
or  bends  before  the  compressing  force  of  suddenly  exerted  intra- 
abdominal pressure.  My  judgment  has  been  often  biased  in  favor 
of  a  malignant  growth  being  present,  when  I  have  found  that  the 
onset  heematuria  was  apparently  the  result  of  slight  indirect  violence. 

The  Diagnostic  Significance  of  tie  Effects  of  Rest,  Abrupt  Movements, 
and  Exercise,  during  the  Course  of  a  Case  of  Hcematuria. 

The  haematuria  of  stone  in  the  kidney  pelvis,  in  the  bladder  or 
prostate  usually  subsides  upon  rest  being  taken  in  the  recumbent 
posture.     In  all  cases  in  which  the  subjacent  mucous  membrane  is 


SYMPTOMLESS   HEMATURIA.  545 

not  ulcerated  the  bleeding  is  established  or  aggravated  only  by  abrupt 
movements  or  exercise. 

It,  therefore,  stands  as  general  rule  that  when  the  hemorrhage  is 
noticed  to  increase  toward  night-time  and  to  be  found  diminished 
on  rising  in  the  morning,  and  when  pain  and  irritability  of  the  bladder 
increase  and  decrease  in  the  same  proportion  and  under  similar  con- 
ditions, a  stone  is  the  probable  cause  of  the  bleeding. 

It  must,  however,  be  remembered  that  occasionally  exercise  has 
the  same  effect  in  increasing  the  bleeding  of  hard  carcinoma  of  the 
bladder,  large  villous  growths  of  the  bladder,  tubercular  ulceration 
of  the  bladder,  and  large  senile  prostate. 

It  is  noticeable  that  when  hsematuria  persists  in  spite  of  pro- 
longed rest  it  is  usually  from  ulceration  or  morbid  growth.  Thus 
carcinoma  of  the  bladder  or  kidney  frequently  bleeds  most  at  nights, 
— the  hemorrhage  rather  diminishing  during  the  day. 

Symptomless  HsBm^aturia. 

The  diseases  which  usually  evoke  hsematuria  before  inducing  pain 
or  any  other  concomitant  symptoms  of  urinary  trouble  are  those 
which  lie  latent  and  unsuspected  until  the  effusion  of  blood  draws 
attention  to  the  urine  and  prompts  investigation.  Thus  there  is 
every  reason  to  believe  that  renal  carcinoma  or  sarcoma,  contracting 
granular  kidney,  villous  or  soft  carcinomatous  growths  of  the  bladder 
when  situated  at  a  distance  from  the  urinary  outlets,  and  rare  cases 
of  renal  and  vesical  stone  exist  for  variable  periods  before  a  chance 
congestion,  an  extra  exertion,  or  some  slight  indirect  violence  evokes 
the  hsematuria  which  discloses  their  existence. 

It  is  always  difficult  to  group  diseases  with  accuracy  on  the  basis 
of  single  symptoms,  but  the  following  table  roughly  differentiates 
the  causes  of  the  symptomless  variety : 

fa.  Renal.         j  Blood  usually  profuse  and  j  Malignant  disease  of  kid- 
\      bright ;  intimately  mixed,  j      ney. 

Renal  tender-  j  Blood  moderate,  but  bright ;  \  ^'sTp'hS)iii1Siacdis- 
,       .,,        J      ^<^s«-  <      mtimately  mixed.  j      ease ;  rare  renal  stone, 

termittent.  ,-^_   Sessile   or  short-pedi- 

Famlesslor  r^3^     a  n       w      .1     I      cled     benign     growth 

months.-^  r Blood    usually    intimately  ^^^^  ^rj|^3    of 

mixed,  but  probably  no-  |      ^j-ethra 
lb.  Vesical.       ^      ticed  pure  at  end  of  clear^  ^    Epitheliomatous      tu- 
mictuntipnat  some  time        ^^^  ^^  posterior   wall 
l^     or  other  m  course  of  case.  sides 

3.  Rare  vesical  stone. 

*  The  pain  due  to  the  passage  of  renal  and  vesical  clots  is  not  of  course  taken 
into  account,  being  merely  a  transient  epiphenomenon. 
Vol.  I.— 35 


Onset    sud- 
den. 
Course    in- 


546  FENWICK — DISEASES  OF  THE  URINE. 

In  all  these  cases  it  will  be  noticed  that  the  onset  of  the  bleeding 
is  sudden,  and  often  spontaneous ;  that  it  is  intermittent  in  its  ap- 
pearance, the  urine  between  the  hemorrhages  being  absolutely  normal, 
with  the  exception  of  that  passed  in  granular  kidney,  and,  lastly, 
that  no  pain  is  experienced  in  the  earlier  stages  in  the  region  affected. 

The  Eenal  Geoup  of  Symptomless  HiEMATUEiA. 

The  renal  group,  which  includes  renal  cancer,  syphilis,  Bright's 
disease,  congestion  due  to  cardiac  disease,  and  rare  cases  of  renal 
stone,  can  only  be  sei^arated  from  the  vesical  group,  in  the  absence  of 
a  cystoscopic  examination,  on  clinical  grounds.  These  are  frequently 
unsatisf actor}'.  They  consist  for  the  most  part  in  a  careful  and  criti- 
cal estimation  of  all  the  onset  symptoms  and  a  thorough  examination 
of  the  patient  on  the  lines  just  laid  down.  Much  stress,  as  will  be 
seen  by  the  table,  is  placed  upon  the  more  perfect  admixture  of  the 
urine  and  localized  renal  tenderness  on  pressure.  The  characteris- 
tics of  those  grouped  together  as  renal  are  as  follows : 

Malignant  Disease  of  the  Kidney."^ 

Our  knowledge  of  the  varieties  of  malignant  disease  of  the  kidney 
in  the  adult  is  at  present  inexact ;  the  clinical  picture  of  the  disease 
must,  therefore,  be  uncertain.  The  commonest  form  of  malignant  dis- 
ease in  the  adult  kidney  is  encephaloid  cancer,  but  it  has  been  lately 
proved  that  sarcoma  of  the  capsule  of  the  kidney,  as  well  as  of  the 
suprarenal  body,  is  also  not  infrequent.  The  cases  recorded  of  the 
latter  diseases  are  too  few  in  number,  however,  to  settle  definitely  as 
to  whether  hsematuria  is  a  delaj^ed  symptom  in  these  sarcomata  or 
not.  I  believe  that  in  sarcomatous  cases  a  renal  tumor  is  discoverable 
before  blood  appears  in  the  urine.  In  children,  in  whom  probably 
most  renal  growths  are  sarcomata,  the  tumor  is  usually  recognizable 
before  the  hsematuria  ensues.  Thus  Lebert,  who  has  collected  over 
fifty  cases,  notes  that  in  thirty-six  cases  a  renal  tumor  appeared 
first ;  and  in  nineteen  cases  hsematuria  was  the  first  symptom. 

Character  of  Ha^maturia  in  3IaUgnant  Disease  of  the  Kidney  in  the 
Adult. — Onset:  The  patients  are  mostly  men  about  the  age  of  fifty. 
The  ages  of  my  cases  were  64,  53,  53,  54,  44,  52,  42,.  45,  4,  54,  62,  51, 
49,  52,  60,  49,  47.  In  the  large  majority  of  patients  whom  I  have  seen 
there  has  been  no  warning,  previous  to  the  hemorrhage,  that  the  kidney 
was  diseased.  In  six  cases  out  of  seventeen  the  hemorrhage  has  been 
sudden,  unexpected,  and  profuse,  following  almost  directly  upon  some 
form  of  violence,  such  as  a  blow  on  the  loin  (two  cases) ;  severe  exer- 

*  Hsematuria  occurs  in  50  per  cent,  of  renal  carcinoma  (Ebstein) . 


RENAL   GROUP   OP   §piPT0MLE8S   HiEMATURIA.  547 

cise  (one  case) ;  severe  coughing  (one  case) ;  lifting  a  heavy  weight 
(one  case) ;  bending  down  to  open  the  lowest  drawer  of  a  bureau 
(one  case).  In  the  remaining  eleven  cases  the  hemorrhage  has  been 
spontaneous  and  usually  bright  in  character  at  the  very  commence- 
ment. In  all  cases  rest  in  bed  has  x^romptly  checked  the  bleeding, 
but  on  the  patient  returning  to  active  habits  it  has  recurred,  sometimes 
to  an  alarming  extent.  Even  travelling  in  a  jolting  conveyance  or  a 
train  has  reinduced  the  hemorrhage.  Clots  of  two  forms  appear  early, 
or  occasionally  in  the  course  of  the  disease — either  the  massy  irregu- 
lar clots  which  are  formed  in  the  bladder  from  the  arterial  blood 
poured  into  that  viscus  along  the  ureter,  or  the  long  worm-like  clots, 
which  are  casts  of  the  ureteral  canal.  I  have  seen  these  long  clots 
only  after  traumatic  rupture  of  the  kidney  and  in  malignant  disease. 
I  believe  they  are  rarely  noticed  in  any  other  form  of  renal  hemor- 
rhage. Specimen  No.  3601  A  in  the  museum  of  the  Eoyal  College  of 
Surgeons  is  an  exception.  It  shows  a  right  kidney  laid  open  longi- 
tudinally to  display  a  large  branched  clot  which  in  the  recent  state 
filled  the  pelvis  and  calyces  and  extended  several  inches  down  the 
ureter.  The  right  renal  vein  was  thrombosed,  but  the  corresponding 
artery  was  patent.  This  specimen  was  removed  from  a  woman  aged 
thirty-six,  whose  urine  became  albuminous  but  not  bloody  shortly 
before  her  death,  which  occurred  suddenly  from  pulmonary  embol- 
ism. In  rare  instances  the  ureteral  casts  have  been  found  to  be  com- 
posed of  sarcoma  cells  and  blood  (St.  George's  Hosjjital  Museum, 
42  C).     Another  similar  case  is  recorded  by  Penrose." 

The  bleeding  often  ceases  abruptly,  the  water  being  heavily 
charged  with  bright  red  blood  on  one  evacuation  and  at  the  next  it  is 
crystal-clear.  This  sudden  change  is  due  to  temporary  corkage  of  the 
ureter  with  a  long  vermicular  clot.  This  clot  will  probably  be  grad- 
ually decolorized  and  expelled  at  some  subsequent  urination  in  the 
shape  of  a  worm  of  a  whitish  fawn-color,  or  even  buff-colored  or 
black.  Of  all  renal  hemorrhage,  that  which  proceeds  from  a 
growth  is  by  far  the  most  alarming.  In  some  cases  it  has  been  so 
profuse  as  quickly  to  blanch  the  patient,  and  to  render  him  breathless 
on  the  slightest  exertion ;  in  one  case  the  patient  was  blind  for  some 
days  from  retinal  anaemia.  The  urine  is  colored  variously  from  the 
admixture  of  blood,  the  color  of  thick  cocoa  or  porter,  dark  red,  bright 
arterial — in  fact,  every  variety,  with  the  possible  exception  of  the  tarry 
bleeding  of  malignant  malaria,  is  simulated.  Yet,  notwithstanding 
this  change  of  front,  the  urine  will  be  usually  clear  between  the  at- 
tacks, of  fair  specific  gravity,  and  contain  only  a  trace  of  albumin.* 

*Thiriar  ]ms  stated  that  urea  is  diminished  in  malignant  disease  of  the  kidney. 


548  FENWICK — DISEASES   OF  THE   UEIKE. 

The  profuse  hemorrliage  of  reual  carcinoma  is  sometimes  rivalled  by 
that  of  vesical  malignant  growth.  In  the  latter,  however,  cystitis 
and  the  necrosis  of  the  growth  rapidly  supervene  and  produce  a 
typical  stinking  urine,  which  condition  is  never  noticed,  I  believe,  in 
uncomplicated  renal  cancer  unless  the  practitioner  has  introduced 
septic  material  by  catheterism,  sounding,  or  injudicious  washing. 

Pain. — Mild  renal  colic  may  arise  from  transient  impaction  of  a 
clot  in  the  ureter,  and  a  guide  to  the  kidney  affected  is  at  once  estab- 
lished ;  but  the  pain  ceases  directly  the  clot  is  expelled  into  the  blad- 
der, and  the  shape  and  apj)earance  of  the  coagulum  in  the  urine  inter- 
pret the  cause  and  character  of  the  renal  suffering.  When  the  clots 
in  the  bladder  are  large  there  may  be  some  difficulty  and  straining 
in  evacuating  them ;  nay,  there  may  be  even  temporary  retention,  but 
when  the  clots  are  evacuated  the  vesical  colic  subsides.  With  these 
exceptions  and  that  of  the  hsematuria,  renal  carcinoma  is  usually  a 
symptomless  affection  at  first.  Of  those  patients  who  have  been 
under  my  care  not  one  had  pain  beyond  a  slight  backache  and  feeling 
of  lassitude,  due  to  the  excessive  loss  of  blood  for  the  first  nine  months. 
Pain  in  the  back  was,  however,  induced  as  the  growth  progressively 
increased  and  involved  the  surrounding  structures.  The  hemorrhage, 
probably  by  depleting  the  vessels  and  relieving  tension,  usually  lessens 
the  pain  in  the  later  stages. 

Pain  is,  however,  experienced  if  swelling  from  nephritis  ensues. 
In  two  cases  not  included  in  the  above  I  have  known  great  pain  pro- 
duced by  septic  inflammation  of  the  carcinomatous  kidney.  In  both 
cases  I  believe  that  the  acute  suppurative  nephritis  was  the  result  of 
catheterism,  and  death  occurred  in  the  very  earliest  stage  (compare 
section  on  Treatment) . 

Tumor. — Probably  the  very  large  renal  tumors  are  sarcomatous. 
The  true  carcinomata  rarely  reach  a  large  size  without  causing  much 
pain  and  constitutional  effects. 

Varicocele  occasionally  appears  in  the  later  stages  of  renal  cancer, 
and  is  a  very  important  additional  evidence  of  impediment  by  pres- 
sure of  a  malignant  growth ;  so  much  so  that  if  a  varicocele  suddenly 
makes  its  appearance  in  a  patient  about  the  age  of  fifty  it  impera- 
tively calls  for  an  immediate  examination  of  the  kidney  of  the  corre- 
sponding side. 

Frequency  of  micturition  apart  from  that  temporarily  induced  by 
clot  retention  *  is  not  common.  Obstinate  constipation,  flatulence, 
and  other  digestive  troubles  are  often  complained  of. 

Malaise  and  cachexia  are  noticed  in  rare  instances  even  before  the 

*  I  have  known  retention  ensue  without  blood  clot. 


EENAL  GROUP  OP  SYMPTOMLESS  HEMATURIA.  549 

hsematuria  or  tumor,  and  are  to  be  regarded  as  an  ominous  sign  of 
dissemination.  Usually  the  cachexia  is  due  to  loss  of  blood  in  the 
earlier  stages. 

Typical  Cases  of  Renal  Carcinoma, 

Case  1.  Renal  Carcinoma,  Hemorrhage,  Retinal  Ancemia. — G.  W., 
set.  44,  under  Mr.  McCarthy.  Twelve  months  previous  to  coming 
under  my  observation  the  patient,  being  in  perfect  urinary  health, 
was  lifting  a  moderate-sized  weight  when  he  felt  something  snap  in 
his  left  side.  He  passed  a  large  quantity  of  liquid  blood. ,  The  hem- 
orrhage was  arrested  by  a  week's  medicine  and  rest  in  bed.  It  re- 
curred upon  his  going  back  to  work,  and  large  worm-shaped  clots 
came  away  with  the  urine.  Since  this  recurrence,  the  character  of 
the  attacks  has  always  been  the  same.  The  hemorrhage  is  profuse — 
in  some  instances  alarmingly  so,  but  rest  in  bed  checks  it.  On  re- 
suming his  occupation  the  blood  returns  with  great  violence.  No 
pain  and  no  frequency  of  micturition  were  noticed.  The  day  I  exam- 
ined him  with  the  cystoscope  the  hemorrhage  had  completely  ceased. 

Cystoscojjy. — February  7th,  1889.  Bladder  healthy  throughout. 
Left  ureteral  orifice  is  marked  by  a  red  blush,  the  lips  are  pouting ; 
right  ureteral  .opening  healthy;  prostate  small;  no  renal  tumor; 
diagnosis,  probably  left  renal  carcinoma.  This  occurred  in  the  early 
days  of  electric  cystoscopy,  and  as  my  incomplete  diagnosis  did  not 
satisfy  one  of  my  colleagues,  I  had  the  patient  watched.  He  became 
"blind"  for  four  days  in  Seabrook  Ward,  Hemel  Hempstead  Infirm- 
ary, from  excessive  loss  of  blood,  and  finally  drifted  into  the  In- 
firmary in  St.  George's  in  the  East,  under  Dr.  Harris,  where  he  died. 

Dr.  Elwin  Harris,  to  whom  I  applied  for  a  record  of  the  autopsy, 
very  kindly  wrote  me  a  letter  about  the  patient  (dated  October  13th, 
1891),  in  which  he  says:  "George  W.  was  a  case  of  profuse  hsema- 
turia,  which  I  erroneously  diagnosed  as  malignant  disease  of  bladder. 
I  well  recollect  my  surprise  at  finding  the  bladder  quite  free  from  dis- 
ease at  the  post-mortem.  I  signed  the  certificate  'Carcinoma  of  kid- 
ney.'" 

Case  2.  Renal  Carcinoma,  Repeated  Retention. — B.,  set.  52.  About 
a  year  previous  to  this  patient  coming  under  my  observation  he 
passed  a  clot  of  blood  "like  a  fly."  For  fourteen  days  he  was  free 
and  then  another  clot  aj^peared.  About  this  time  he  remarked  that 
he  was  losing  his  elasticity  of  spirits,  that  he  tired  easily  and  was 
glad  to  sit  down  and  rest.  A  month  after  the  appearance  of  the  clot, 
a  short  railway  journey  having  been  taken,  he  was  seized  with  reten- 
tion. A  catheter  was  passed  and  much  difficulty  was  experienced  in 
clearing  the  bladder  of  many  large  black  clots.  He  remained  free 
from  all  symptoms  for  two  and  a  half  months,  when  he  had  a  similar 
attack  of  retention.  Again  there  was  an  entire  absence  of  symptoms 
until  one  day  he  noticed  a  constant  desire  to  micturate,  which  he 
complied  with.  Every  ten  or  fifteen  minutes  he  passed  without  diffi- 
culty a  little  clear  water.  Accompanying  this  was  the  greatest 
sense  of  discomfort  and  miserable  restlessness.  He  did  not  know 
whether  to  sit  down  or  stand  up.  This  mild  urethral  spasm  con- 
tinued for  an  hour  or  two.     Ho  then  drank  a  quantity  of  hot  tea 


550  PENWIOK — DISEASES  OF  THE  UEINEo 

and  immediately  obtained  relief  botli  from  the  pain  and  from  the  con- 
stant desire  to  urinate.  Shortly  afterward  he  passed  a  long  piece  of 
tissue  which  was  pronounced  to  be  a  worm  but  which  really  turned 
out  to  be  a  ureteral  clot.  He  never  suif  ered  from  these  uneasy  symp- 
toms again.  He  has  noticed  that  he  has  been  losing  flesh  and  grow- 
ing ansemic.     A  few  months  ago  a  right-sided  varicocele  appeared. 

When  he  consulted  me  there  was  a  well-marked  hard  movable 
right  renal  growth.  He  had  no  frequency  of  micturition  and  no 
pain.  He  was  merely  annoyed  by  recurrent  attacks  of  profuse  hem- 
orrhage and  obstinate  constipation.  There  was  no  history  of  cancer 
in  the  family,  but  the  patient  had  had  syphilis  twenty  years  previ- 
ously and  had  been  invalided  home  from  India  for  phthisis.  I  ad- 
vised nephrectomy,  and  I  heard  a  few  weeks,  after  that  the  patient 
had  taken  another  opinion  and  that  the  right  kidney  had  been  suc- 
cessfully removed  and  found  to  be  carcinomatous. 

Ch^amdar  Kidney,  Sy2:)hUoma  of  the  Kidney,  Renal   Congestion  from 
Cardiac  Back  Pressure,  Bare  Cases  of  Benal  Stone. 

This  group  of  renal  disorders  may  furnish  a  brightish  bleed- 
ing, but  rarely  in  sufficient  quantity  to  cause  clotting.  Usually  the 
urine  varies  greatly  in  hue  from  a  rosy  tinge  to  the  darker  colors. 
It  also  contains  evidences  of  renal  disease  in  the  periods  of  calm, 
when  blood  is  absent,  in  the  form  of  low  specific  gravity,  casts,  or 
albumin. 

Chronic  Brighfs  Disease. — The  occasional  brightness  of  the  blood  in 
acute  Bright' s  disease  is  of  course  well  recognized,  but  I  do  not  think 
that  the  profession  at  large  has  yet  realized  that  a  very  abundant 
and  intermittent,  often  brightish  hemorrhage  may  occur  in  chronic 
contracting  granular  kidney.  This  occasional  brightness  is  a  source 
of  fallacy.  I  have  met  with  various  examples,  and  have  thought, 
until  quite  recently,  that  the  subject  had  been  overlooked,''  but  my 
attention  has  lately  been  drawn  to  papers  on  the  same  subject  by  Dr. 
West  and  Mr.  Bowlby'""  which  were  published  before  my  note.  Dr. 
West  gives  three  valuable  cases,  and  mentions  the  following  which 
came  Tinder  Dr.  Sharkey's  care  at  St.  Thomas'  Hospital:  "The  pa- 
tient, a  young  girl,  passed  so  much  blood  with  the  urine  that  the 
bladder  was  sounded,  and  the  surgeon,  failing  to  find  a  stone,  sug- 
gested dilatation  of  the  urethra  and  digital  exploration  of  the  blad- 
der. To  this  Dr.  Sharkey  did  not,  for  good  reasons,  consent,  and 
the  patient  died.  No  stone  was  discovered  at  the  autopsy  but  mark- 
edly granular  kidneys."  " 

The  symptomless  cases  I  have  met  with  form  about  twelve  per 
cent,  of  the  obscure  hsematurias  which  I  have  examined  with  the  cys- 
toscope.     I  believe,  as  these  cases  progress,  frequency  of  micturi- 


EENAL  GEOUP  OF  SYMPTOMLESS  HEMATURIA,  551 

tion  and  renal  pain  supervene,  and  they  fall  into  the  group  of  hsema- 
turia  with  symptoms  {q.v.) 

Not  unfrequently  the  hemorrhage  has  ensued  upon  a  slight  strain 
or  fall  on  the  buttocks,  and  much  difficulty  has  subsequently  arisen 
in  stating  positively  whether  the  slight  symptoms  of  renal  disease 
found  in  the  urine  were  the  outcome  of  the  injury  or  preceded  it.  I 
believe  in  many  of  these  cases  a  degeneration  pre-exists,  and  the  kid- 
ney tissue,  being  friable,  sj^lits  more  easily  than  would  healthy  renal 
substance  and  heals  proportionately  more  slowly. 

The  cases  are  recognized  by  the  condition  of  the  urine,  a  low  spe- 
cific gravity,  the  presence  of  albumin  and  casts ;  to  which  may  be 
added  cardiac  and  retinal  changes  in  advanced  stages.  These  cases 
heal  with  prolonged  rest  and  milk  diet.  I  have  recently  met  with  a 
case  of  hsematuria  in  which  the  blood  was  proved  on  post-mortem  to 
emanate  from  congenital  cystic  kidney ;  clinically,  however,  it  could 
not  be  diagnosed  from  the  contracting  granular  kidney  except  by  the 
severe  pain  in  the  renal  region. 

Schede'*  of  Hamburg  records  the  following  interesting  case  of  un- 
controllable renal  hemorrhage : 

A  man,  aged  50,  passed  bloody  urine  for  the  first  time  after  a 
cold  drink.  He  had  frequently  before  noticed  a  sensation  of  cold  in 
the  left  lumbar  region.  If  he  remained  quietly  in  bed  the  bleeding 
ceased,  but  it  returned  directly  he  got  up.  Styptics  did  not  relieve 
the  condition,  and  the  blood  was  proved  by  catheterism  of  the  ureters 
to  issue  from  the  left  ureter.  Left  nephrectomy  was  performed ;  the 
kidney  substance  was  found  to  be  very  friable,  and  microscopical 
examination  of  it  revealed  what  was  invisible  to  the  eye,  viz.,  an 
anaemic  condition  interspersed  with  small  petechige,  and  decayed 
cylinders  covered  with  red  blood-cells. 

Syphiloma. — I  have  encountered  undoubted  cases  of  renal  syphi- 
loma which  have  been  marked  by  a  brightish  haematuria.  The 
bleeding  in  each  case  was  controlled  only  by  iodides.'^ 

It  must  be  stated,  however,  that  recent  clinical  experience  points 
rather  to  syphilis  of  the  kidney  producing  symptoms  of  pain  without 
haematuria.  Thus  Dr.  Israel  ^°  reports  two  cases  of  syphilis  of  the 
kidney  which  occasioned  a  tumor : 

Case  1. — A  girl,  aged  23,  after  increased  thirst,  stomach 
cramps,  and  frequency  of  micturition,  suffered  from  continuous  pain 
in  the  back  which  was  later  on  localized  to  the  right  side.  There 
was  loss  of  flesh,  and  a  tumor  developed  in  the  right  renal  region. 
Anti-syphilitic  treatment  was  instituted,  and  appeared  to  give  good 
results  for  a  time,  but  as  collections  of  flattened  cells,  agglomerated 
into  rounded  masses  and  surrounded  by  a  species  of  girdle  composed 
of  fusiform  cells,  began  to  appear  in  the  urine  in  the  form  of  a  whit- 
ish deposit,  an  exploratory  incision  was  made,  and  the  kidney  was 


552  FENWICK — DISEASES   OF  THE  URINE. 

found  so  altered  tliat  it  was  finally  extirpated.  Recovery  was  rapid. 
Examination  of  the  kidney  showed  the  tumor  to  consist  of  syphilitic 
interstitial  nephritis,  with  hyperplastic  peri-  and  para-nephritis. 

Case  2. — A  male,  aged  39,  with  syphilitic  and  malarial  ante- 
cedents, complained  of  a  continuous  pain  on  the  left  side,  with 
swelling  at  the  tenth  rib.  An  abscess  of  the  spleen  was  thought  of, 
and  an  incision  was  made,  releasing  a  yellowish  curdy-white  mate- 
rial, but  no  pus ;  a  fistula  remained.  The  kidney  was  finally  diag- 
nosed as  tubercular  and  was  extirpated.  The  microscope  revealed 
gummatous  degeneration  without  a  trace  of  tubercle. 

Congestion  in  Cardiac  Disease. — I  have  come  across  quite  a  num- 
ber of  cases  of  symptomless  renal  hsematuria  which  I  could  only 
account  for  by  the  supposition  that  they  were  due  to  the  backward 
pressure  exerted  by  cardiac  disease,  but  I  have  no  post-mortem 
evidence  in  support  of  this  "sdew. 

Bare  Cases  of  Stone  in  the  Kidney. — It  is  considered"  that 
hsematuria  is  the  most  important  clinical  symptom  of  renal  calculus ; 
and  though  I  am  inclined  to  dissent  from  this  view  and  to  place  pain 
as  the  most  characteristic  feature  of  renal  stone,  yet  I  feel  sure  that 
in  rare  cases  in  children  and  young  adults  hsematuria  may  be  the 
only  symptom  in  the  early  stages  of  this  affection.  The  character 
which  apparentl}^  stamps  it  is  the  marked  effect  of  exercise  in  increas- 
ing or  producing  the  bleeding.  It  may  be  that  in  children  the  pain 
of  renal  calculus  is  often  misunderstood  and  that  which  is  complained 
of  is  vaguely  termed  "stomach  ache,"  and  it  is  accepted  as  such  by 
the  mother  and  the  physician.  I  have  seen  children  passing  blood 
and  crystals  of  uric  acid  who  were  said  to  suffer  no  jjain,  but  cross- 
examination  elicited  the  fact  that  they  occasionally  complained  of  un- 
easiness and  cramp  in  the  stomach.  The}^  have  subsequently  passed 
calculi.  Criticism  might  condemn  the  introduction  of  this  group 
among  the  symptomless  hsematurias,  and  it  would  be  just,  were  it 
not  for  the  fact  that  in  the  adult  haematuria  also  occasionally  occurs 
in  renal  stone  without  other  symptoms  being  present.  In  time, 
however,  other  symptoms  supervene. 

Case  1. — A  little  girl  was  observed  to  pass  clotted  blood  and  urine 
on  the  floor  at  the  age  of  two.  For  three  years  the  hsematuria  inter- 
mitted and  was  quite  painless.  Sometimes  the  urine  was  very  bright, 
and  at  other  times  smoky.  When  she  came'under  my  observation 
she  was  a  pasty-faced  child  five  years  of  age  with  a  tender  right  kid- 
ney. The  urine  was  clear  but  deposited  a  thick  layer  of  crystals  of 
phosphate  of  lime.  There  was  no  frequency  of  urination.  I  advised 
course  of  lime  juice  and  water  and  luckily  she  passed  a  small,  smooth 
stone  at  the  end  of  a  fortnight,  the  expulsion  being  preceded  by  in- 
tense pain  in  the  belly.     The  child  has  since  been  well. 

Case  2. — I  was  asked  to  examine  with  the  cystoscope  a  healthy 


VESICAL  GROUP  OP- SYMPTOMLESS  HJEMATtJRLl.  553 

young  man  aged  26,  in  order  to  ascertain  the  source  of  a  symptomless 
hsematuria.  At  the  age  of  17  he  had  noticed  that  he  passed  dark-col- 
ored bloody  urine  after  a  rapid  walk.  It  soon  ceased,  but  it  returned 
at  rare  intervals  and  after  great  exertion.  He  suffered,  however,  no 
pain  or  inconvenience  of  any  sort.  At  the  age  of  24  he  was  circum- 
cised, and  after  the  operation  he  again  passed  dark-colored  blood. 
The  attacks  of  hsematuria  now  became  more  frequent  and  any  jolting 
induced  the  bleeding,  but  it  was  never  bright.  If  he  remained  at  rest 
the  urine  promptly  cleared.  The  urine  was  of  low  specific  gravity 
and  the  morning  sample  was  quite  clear,  but  it  became  murky  with 
pus  toward  night.  There  was  some  tenderness  over  the  right  loin. 
Cystoscopy  showed  the  bladder  to  be  healthy  in  every  part  and  the 
diagnosis  was  left  open,  though  it  was  suggested  that  tuberculosis  of 
the  kidney  might  be  present.  I  was  able  to  follow  the  case  for  three 
years.  Pus  gradually  became  constant  in  the  urine  and  was  passed  in 
large  quantities ;  a  distinct  tumor  of  the  right  kidney  appeared.  Ex- 
ploratory nephrotomy  was  performed  and  a  large  branched  calculus 
removed. 

Villous  Groivth  of  the  Pelvis  of  the  Kidney,  and  the  Hcematuria  of 
the  Hemorrhagic  Diathesis. 

Such  cases  as  villous  growth  of  the  renal  pelvis  and  the  renal 
bleeding  in  hemorrhagic  diathesis  are  too  infrequent  to  need  discus- 
sion. Senator"  records  a  case  of  the  latter  and  others  have  since  ap- 
peared in  the  literature.     Senator's  case  was  the  following: 

A  young  lady  suffered  from  long-standing,  frequently  recurring, 
and  profuse  hsematuria,  proved  by  cystoscopic  examination  to  come 
from  the  right  ureter.  There  was  no  pain  and  her  age  discouraged 
the  diagnosis  of  malignant  disease.  She  belonged  to  a  family  of 
bleeders,  and  her  father  and  mother  were  cousins.  As  a  last  resource 
the  right  kidney  was  extirpated.  The  result  was  most  favorable,  as 
two  days  after  the  operation  the  hsematuria  disappeared  and  did  not 
return.  The  kidney  appeared  quite  normal.  Senator  thinks  that  this 
case  suggests  that  in  some  instances  haemophilia  is  due  to  a  local  de- 
fect in  the  walls  of  the  vessels. 

The  Vesical  Group  of  Symptomless  HiEMATURiA. 

The  vesical  group  of  symptomless  haematuria  includes  sessile  or 
short  pedicled  benign  growths  of  the  bladder,  situated  away  from  the 
urethral  orifice,  *  soft  ei>ithelioma  in  the  early  stages,  springing  from 
the  posterior  wall  of  the  bladder  and  occasional  cases  of  vesical  stone 
in  males  above  the  age  of  fifty.     The  differentiation  of  these  three 

*  These  constitute  92  per  cent,  of  all  villous  papillomata,  and  the  distinction  is 
made  because  in  8  per  cent,  the  h.-Bmaturia  is  preceded  by  vesical  irritability  induced 
by  the  growth  falling  over  the  urctJiral  orifice. 


554  FENWICK — DISEASES  OF  THE  UEINE. 

subsections  is  establisliecl  by  the  degree  of  blood  in  tlie  urine,  the 
duration  of  symptoms,  and  other  items  which  will  be  referred  to. 

The  Life  History  of  Hemorrlmge  from  Benign   Growths,  which  are 
Situated  Away  from  the  Orifice  of  the  Bladder. 

The  history  is  often  of  long  duration — a  matter  of  years,  not 
months.  Usuallj^  the  bleeding  commences  insidiously ;  perhaps  it  ap- 
pears in  the  form  of  darkish  clots  like  flies,  only  to  disappear  in  a 
few  days,  or  the  urine  may  be  merely  discolored,  or  a  little  blood 
maj-  be  passed  at  the  end  of  clear  micturition,  or  the  whole  secretion 
may  be  of  a  dark  coffee-color.  The  patient  may  connect  the  onset  with 
over-fatigue,  but  I  believe  this  is  uncommon.  It  is  also  rare,  as  far 
as  my  experience  goes,  for  a  x^rofuse  arterial-colored  hemorrhage  to 
form  the  onset  attack.  The  htematuria  ceases  as  spontaneously  as 
it  commenced,  but  it  recurs  unexi3ectedly,  causelessly,  at  longer  or 
shorter  inteiwals.  As  the  tumor  increases  in  size,  the  length  of  the 
periods  of  rest  appears  to  decrease  and  the  loss  to  be  more  profuse. 
The  bleeding  is  unaccompanied  by  any  other  symptom ;  neither  fre- 
quency of  micturition,  pain,  nor  stoppage  of  the  stream  is  noticed. 

The  larger  the  tumor  is,  or  the  wider  the  area  which  is  occupied 
by  the  base,  the  greater  is  the  tendency  for  the  bleeding  to  recur 
after  exercise  or  over-fatigue.  In  the  male,  coition  will  sometimes 
induce  an  attack  or  increase  the  bleeding.  It  is  usually  more  under 
the  control  of  rest  than  hemorrhage  from  a  malignant  surface. 
Probably  it  will  be,  now  and  again  in  the  course  of  the  case,  of  a  dis- 
tinct vesical  type,  i.e.,  bright  blood  will  appetir  at  the  finish  of  a 
stream  of  clear  urine. 

The  hemorrhage  is  rarely  of  the  violent  arterial  type,  though  I 
have  known  one  or  two  jjatients  blanched  with  the  loss ;  usually  it  is 
less  furious  and  darker.  If  the  deeper  layers  of  the  growths  become 
carcinomatous  I  believe  the  hemorrhage  becomes  more  profuse  and 
more  persistent.  As  the  neoplasm  approaches  the  urethral  orifice, 
either  by  the  lengthening  of  its  stalk  or  by  overgrowth,  it  is  exposed 
to  greater  damage,  the  bleeding  is  more  severe,  and  other  symptoms, 
such  as  irritability  of  the  bladder,  and  stoppage  of  the  stream,  also 
appear.  Sessile,  closelj-felted  villous  growths  bleed  less  often  and 
less  profusely,  and  attain  a  greater  age  than  other  forms. 

The  hsematuria  may  be  -checked  for  a  time  by  intercurrent  disease, 
e.g.,  carcinoma  of  the  breast,  acute  rheumatism,  or  some  fever,  but 
recurs  after  the  interloper  has  been  removed  or  subsides. 

Lastly,  when  the  period  of  cystitis  is  ushered  in  (either  from 
change  in  the  character  of  the  base  of  the  growth,  or  from  the  tumor 


TESICAL  GROUP  &e  SYMPTOMLESS  HiEMATURlA.  555 

having  begun  to  necrose,  or  from  injudicious  exploration  on  the  jjart 
of  the  surgeon),  the  appearance  of  the  blood  changes,  pus  becomes 
mixed  with  it,  and  the  hemorrhage  may  be  permanently  arrested  by 
the  inflammatory  plugging  of  the  vascular  supply  of  the  surface  of  the 

tumor  which  takes  place  on  the  establishmant  of  severe  cystitis. 

« 

Illustrative  Case  (selected from  150  Cases  of  Vesical  Growth). — 
A  well-built  man,  aged  48,  came  to  me  with  the  following  history. 
Twenty  years  ago,  being  in  perfect  health,  he  noticed  that  he 
was  passing  small  black  clumps  like  flies  in  his  urine.  These  clots 
ceased.  Then  the  urine  became  periodically  colored  with  blood. 
The  hemorrhage  was  affected  neither  by  coition  nor  by  movement,  nor 
by  over-indulgence  in  alcohol.  For  fifteen  years  the  hfematuria  ap- 
peared ofl^  and  on,  causelessly,  and  was  unaccompanied  by  any 
other  symptom.  Five  years  ago  he  began  to  experience  jjain  on 
micturition  of  a  cutting  character.  He  referred  the  pain  to  a  spot 
an  inch  down  the  penis  on  the  under  surface ;  it  seized  him  as  the 
bladder  was  just  emptying.  He  had  passed  clots  accompanied  by  a 
quantity  of  porter-like  urine,  and  at  the  end  pure  blood  had  some- 
times dribbled  away. 

Electric  Cystoscopy.- — On  the  left  side  of  the  bladder  a- large  ses- 
sile fibropapilloma  could  be  seen.  Here  and  there  the  surface  was 
white  and  necrotic.  Its  area  occupied  the  left  side  of  the  base  and 
the  adjoining  left  lateral  wall  for  about  an  inch.  It  encroached  also 
slightly  on  the  anterior  wall. 

I  removed  the  tumor  by  supra-pubic  operation. 

RemarTcs. — It  will  be  noticed  that  for  fifteen  years  no  other  signs 
of  the  vesical  growth  existed  beyond  the  recurrent  hsematuria.  Up 
to  this  date  the  case  falls  into  the  group  of  symptomless  hsematuria. 

Then  he  commenced  to  have  pain  and  obstruction,  which  symptoms 
were  probably  due  to  implication  of  the  urethral  outlet  of  the  bladder, 
and  the  case  now  falls  into  the  group  of  hsematuria  with  symptoms. 

Soft  Malignant  Growth  of  the  Posterior  Wall. — It  will  be  observed 
that,  contrary  to  the  current  teaching,  vesical  carcinoma  is  tabulated 
with  villous  growth  of  the  bladder  as  being  symjptomless.  It  will  be 
remembered  that  Sir  H.  Thompson  "  has  indorsed  the  axiom  enun- 
ciated by  Professor  Gross.  He  asserts :  "  In  most  of  the  cases  in 
which  the  tumor  was  of  the  malignant  type  or  approached  thereto, 
pain  and  frequency  of  passing  water  generally  preceded  the  appear- 
ance of  blood,  sometimes  for  a  considerable  jDeriod  of  time."  I  have 
for  long  been  certain  that  this  is  a  decided  error,  and  submit  that 
such  a  dictum  laid  down  in  pre-cystoscopic  times  should  be  aban- 
doned.'" Seventy-six  per  cent,  of  my  cases  of  cancerous  tumor  of  the 
bladder  show  it  to  be  incorrect.  A  soft  malignant  tumor,  springing 
from  the  j)osterior  wall,  may  grow  quietly,  even  latently,  for  months 
before  it  induces  hsematuria,  and  if  it  is  so  i)laced  as  to  be  out  of  the 


556  PENWICK — DISEASES  OF  THE  URME. 

region  of  tlie  sensitive  neck  of  tlie  bladder  it  evokes  neither  frequency 
of  micturition  nor  pain  until  the  wall  becomes  infiltrated,  the  capa- 
city of  the  bladder  markedly  diminished,  or  until  cystitis  is  induced 
by  the  necrosis  and  irritation  of  the  growth. 

Hie  Life  History  of  Hemorrhage  from  Ilalignant  Gh^oivths. 

Presuming  the  medical  man  to  have  induced  no  cystitis  by  sound- 
ing or  catheterism — and  this  is  uncommon — the  hgematuria  of  soft 
malignant  growth,  situated  away  from  the  neighborhood  of  the  ure- 
ters, may  be  symptomless  for  months,  the  average  duration  of  the 
stage  being  probably  nine  months.  After  this  the  inevitable  cystitis 
supervenes,  or  the  muscle-wall  becomes  infiltrated,  and  frequency  of 
micturition  and  suffering  ensue. 

The  initial  hgematuria  is  sometimes  slight,  as  in  benign  growths, 
but  more  often  than  not  it  is  profuse,  the  urine  being  very  dark  or 
maroon-colored  with  clots.  The  patient  in  many  instances  traces  it 
to  a  slight  indirect  violence.  At  first  it  is  intermittent,  its  return 
usually  dependent  on  exercise,  its  cessation  upon  rest,  but  it  rapidly 
loses  these  characters.  It  becomes  more  or  less  persistent,  and  is  not 
so  easily  affected  hj  drugs.  The  urine  acquires  the  characters  of  the 
washings  of  flesh  and  becomes  offensive.  The  color  becomes  changed 
by  the  alkalinitj^  of  the  urine ;  muco-pus,  debris,  and  phosphatic  grit 
appear  in  the  secretion. 

In  order  to  distinguish  between  these  two  classes  of  hsematuria, 
that  due  to  benign  and  that  the  outcome  of  malignant  growth,  a 
careful  rectal  examination  of  the  bladder  is  to  be  undertaken.  If  any 
hard  infiltrated  area  is  discovered  in  the  base  of  the  bladder  behind 
the  prostate,  the  growth  is  almost  certain  to  be  a  carcinoma  and  not 
of  a  benign  type.  If  with  this  there  is  constant  pain,  if  the  patient 
is  of  an  age  above  forty -five,  if  there  has  been  loss  of  flesh,  if  malaise 
is  present,  and  finally  if  a  history  of  family  carcinoma,  phthisis,  or 
longevity,  is  obtainable,  the  suspicion  of  malignity  is  much  strength- 
ened. 

Type  of  Soft  Succulent  Epithelioma.^Th.Q  following  cases  were 
recorded  ^''  while  the  patients  were  alive.  A  post-mortem  examina- 
tion has  subsequently  been  obtained,  so  that  the  histories  are  now 
comjolete. 

Case  1.  Hcematuria,  Cystoscopy  Revealing  a  Busset-Ch^ay  Growth 
and  an  Altered  llucous  Memhrane ;  Removal  of  the  Former  by  Suc- 
tion, and  Development  of  Cancer  in  the  Latter. — Mr,  O.,  set.  56  (under 
Mr.  Travers  Stubbs).  Five  weeks  before  consulting  me,  being  in 
perfect  urinary  health,  he  suddenly  and  without  warning  passed  a 


VESICAL  GEOUP  OF  SYMPTOMLESS  H^MATUELV..  557 

quantity  of  coffee-colored  urine.  He  suffered  no  pain,  but  had  a 
tenderness  in  the  right  testicle.  Since  this  time  the  urine  has  varied 
in  its  aspect ;  now  and  again  it  has  been  quite  clear  for  a  day  or  two, 
then  it  has  become  very  dark. 

On  passing  the  cystoscope,  a  peculiar  russet-gray  lobulated 
growth  was  seen  hanging  from  the  posterior  wall  of  the  bladder,  and 
swaying  freely  upon  a  pedicle.  The  mucous  membrane  in  the 
immediate  neighborhood  had  an  injected  nodular  ai>i)earance,  ex- 
tremely suggestive  of  commencing  carcinoma.  The  color  of  the  hang- 
ing body  was  very  puzzling.  As  there  was  a  difference  of  opinion 
among  those  present  as  to  its  nature,  I  sucked  it  out  with  a  litho- 
trite  tube  and  ball.  It  looked  like  an  old  blood-clot.  On  section  it 
was  subsequently  found  to  be  necrotic  growth  and  blood-clot.  The 
cystoscope  was  re-introduced  and  the  diseased  site  re-examined. 
There  was  no  bleeding.  A  patch  of  stunted  processes  was  seen  where 
the  stalk  had  been  attached.  As  operative  interference  was  contra- 
indicated  by  the  cystoscope,  injections  were  resorted  to,  and  the  hge- 
maturia  subsided. 

Three  months  after  this  examination  the  patient  visited  me,  look- 
ing hale  and  hearty,  and  declaring  himself  in  the  best  of  health.  His 
general  condition  gave  no  indication  of  carcinoma,  and  I  doubted  its 
existence,  believing  I  had  been  optically  deceived  as  to  the  nature  of 
the  group  of  nodules  on  the  mucous  membrane.  I,  therefore,  re- 
examined him,  and  was  somewhat  astonished  to  see  that  the  grouj) 
of  isolated  nodules  had  grown  into  a  confluent  walnut-sized  tumor 
which  was  deeply  cleft  into  lobules  and  of  a  gelatinous  aspect,  a 
growth  which  I  at  once  recognized  as  a  succulent  epithelioma.  He 
very  gradually  got  worse.  He  suffered  little  pain,  but  his  emaciation 
toward  the  end  was  extreme. 

Death  took  place  two  years  after  the  onset  of  the  hgematuria,  and 
by  the  kindness  of  Dr.  Travers  Stubbs  I  obtained  an  autopsy.  Not 
only  was  the  bladder  filled  with  soft  whitish  growth,  but  the  walls 
had  been  transformed  into  carcinoma  so  that  the  entire  pelvis  was 
filled  with  the  neoplasm.  Both  kidneys  were  in  a  state  of  suppura- 
tive nephritis. 

Case  2.  Hcematuria  of  Two  Years'  Duration;  Calculus;  Lithotrity. 
— No  Decrease  171  the  Amount  of  Hcematuria.  Stalked  Carcino^na^' — 
Mr.  J.,  set.  62,  under  the  care  of  Dr.  Fred  Simms,  who  brought  the 
patient  to  me  in  October,  1888,  with  a  diagnosis  of  vesical  growth. 
The  patient  was  perfectly  sound  until  two  years  ago,  at  which  date 
he  suddenly  had  an  attack  of  painless  hsematuria  after  long  exposure 
and  fatigue.  The  hsematuria  was  typical  of  new-growth ;  and  though 
a  small  calculus  was  discovered  and  crushed,  the  loss  of  l3lood  contin- 
ued unabated.  He  suffered  when  I  first  saw  him  from  no  pain  or  fre- 
quency of  micturition ;  the  hemorrhage  was  persistent,  occurring  after 
micturition.  On  examination  with  the  cystoscope,  a  whitish-gray 
walnut-sized  growth,  evidently  stoutly  pedicled,  was  seen  hanging  from 
the  right  postero-lateral  wall  above  the  right  ureter.  There  was  no 
cystitis ;  the  patient  was  advised  that  the  growth  could  be  removed  by 
operation,  but  that  in  all  ijrobability  it  would  rapidly  recur.  I  saw 
him  nine  months  after  this  (July,  1889) ;  he  was  apparently  in  perfect 


558  FENWICK — DISEASES  OF  THE   UEINE. 

health.  He  suffered,  however,  from  slight  pain  at  the  tip  of  the 
penis  and  in  the  perineum  after  passing  water,  induced  most  likely 
by  the  increased  growth  of  the  tumor.  He  had  intermittent  attacks 
of  bleeding ;  no  cystitis  was  as  yet  present. 

In  March,  1890, 1  received  the  following  from  his  medical  attendant : 
"  Mr.  J.  called  upon  me  early  in  December  and  did  not  appear  much 
worse  or  much  weaker.  He  reminded  me  that  the  year  of  life  given 
him  by  myseK  had  passed;  he  was  bleeding  pretty  steadily.  Soon 
afterward  the  patient  went  to  stay  with  some  friends  in  Somerset- 
shire, and  there  on  January  31st  he  died.  His  friends  and  the  medi- 
cal man  at  Burton  wrote  to  me,  and  it  appears  that  it  was  found  that 
the  epithelioma  had  extended  through  the  base  and  back  of  the 
bladder." 

Vesical  Calculus. 

In  by  far  the  greater  number  of  cases  of  vesical  calculus  (93  per 
cent.  *)  the  onset  bladder  symptoms  consist  of  uneasiness  in  the  vesi- 
cal region,  increased  desire  to  urinate,  increased  frequency  of  mictu- 
rition, an  unsatisfied  feeling  after  urination,  and  some  smarting  or 
pin-pricking  at  the  under  surface  of  the  glans  penis  toward  the  finish 
of  the  vesical  contraction.  But  this  is  not  invariably  so.  In  about 
seven  per  cent,  of  the  cases,  these  being  mostly  made  up  of  men  about 
or  over  fifty  with  some  slight  enlargement  of  the  prostate,  the  first 
noticeable  symptom  is  blood  passed  intimately  mixed  with  the  urine. 
Careful  cross-examination  may  elicit  the  fact  that  an  unusual  amount 
of  exercise  had  been  taken  a  few  hours  previous  to  the  appearance  of 
the  blood ;  and  still  more  frequently  it  will  be  found  that  an  abdom- 
inal attack  of  pain  and  vomiting  has  preceded  this  hgematuria  by  a 
few  weeks.  This  attack  of  abdominal  pain  may  or  may  not  have 
been  a  characteristic  renal  colic.  Often  its  import  has  been  misun- 
derstood- 

The  bleeding  is  usually  seen  only  once,  and  does  not  recur  until 
another  over-exertion  provokes  another  slight  loss.  Unless  the  exer- 
tion or  jolting  has  been  severe  the  amount  of  blood  is  rarely  great. 
Within  a  few  months  of  the  onset,  frequency  of  urination  and  slight 
scalding  or  pain  during  the  act  accompany  the  appearance  of  blood. 
These  three  symptoms,  linked  together,  will  have  a  direct  and  con- 
stant relation  to  exercise.  It  will  be  noted,  however,  that  the  prostate 
may  be  a  little  enlarged  and  that  the  urine  deposits  oxalates  or  uric 
acid.  The  average  practitioner,  finding  the  urine  acid,  clear,  and  of 
good  specific  gravity,  will  probably  be  indisposed  to  diagnose  stone, 

*  The  statistics  are  from  my  notes  of  calculous  cases  and  are  probably  only  ap- 
proximately correct,  for  a  number  of  cases  of  calculi  in  the  atonic  bladder  are  in- 
cluded in  my  lists,  and  these  almost  never  produce  haematuria. 


HEMATURIA  ACCOMPANIEIJ  BY  OTHER  URINARY  SYMPTOMS.  559 

and  will  be  tempted  to  state  that  the  hemorrhage  is  a  relief  to  the 
prostate ;  and  it  is  often  only  when  the  stone  has  produced  a  mild 
attack  of  cystitis  that  the  sound  will  be  used  and  the  cause  detected. 
The  reason  for  the  latency  is,  I  believe,  a  slight  upraising  of  the 
median  lobe  and  a  corresponding  depression  in  which  the  calculus 
lodges,  probably  being  trapped  there  originally  on  its  descent  from 
the  kidney. 

Illustrative  Cases.— H.  J.,  set.  71.  About  two  years  before  com- 
ing under  observation  he  passed  without  pain  and  without  any  fre- 
quency of  urination  a  considerable  amount  of  reddish  blood  which 
was  intimately  mixed  with  the  urine.  The  blood  disapj)eared  with 
rest.  These  attacks  were  intermittent  and  probably  dependent  on 
increased  exertion.  Latterly  he  had  had  pain  after  micturition.  The 
pain  was  increased  by  exercise.  The  prostate  was  enlarged,  the 
urine  was  clear,  sp.  gr.  1.010,  acid,  and  deposited  a  cloud  of  mucus. 

A  small  uric-acid  stone  weighing  124  grains  was  removed  by  litho- 
lapaxy. 

Rev.  H.  C.  P.  aged  71.  Two  months  before  coming  under  ob- 
servation he  passed  blood,  at  first  in  streaks  and  then  intimately 
mixed  with  the  urine.  He  had  no  frequency  of  micturition  and 
no  pain  until  a  few  days  back,  when  he  noticed  a  slight  pricking  in 
the  penis  after  the  act.  He  believed  the  blood  held  some  relation 
to  the  amount  of  gardening  he  did.  The  prostate  was  enlarged,  and 
behind  its  intra-vesical  projection  a  small  pea-sized  stone  was  found 
and  crushed. 

C.  P.  H.,  aged  60.  A  year  ago  he  passed  coffee-colored  urine  with- 
out pain  or  frequency.  This  jjassed  off,  but  a  sense  of  obstruction 
which  he  then  experienced  at  the  neck  of  the  bladder  was  never  quite 
lost.  The  discoloration  of  the  urine  returned  occasionally,  but  it  was 
never  bright  red  until  four  months  before  I  saw  him.  He  then  went 
a  long  drive  in  a  drag  and  bright-red  hsematuria  ensued.  The  color 
was  almost  like  pure  blood  and  accompanying  it  was  much  irritability 
of  the  bladder,  with  straining.  A  few  weeks  ago  he  began  to  suffer 
from  ordinary  symptoms  of  calculus,  ind  on  examination  he  was 
found  to  have  an  oxalate  of  lime  calculus  of  small  size  lodged  behind 
the  upraised  prostate.  The  surface  of  the  oxalate  was  seen  on  cys- 
toscopy to  be  patched  with  white  phosphate  of  lime,  which  had 
probably  been  deposited  during  the  slight  attacks  of  cystitis.  It 
was  removed  by  litholapaxy. 

Hsematuria  Accompanied   by  Other  Urinary  Symptoms. 

In  by  far  the  larger  proportion  of  cases  the  hsematuria  is  not  the 
only  symptom  noticed.  Others — the  outcome  of  functional  distur- 
bances of  the  diseased  organ — usually  make  their  appearance  either 
coincidentally  or  subsequently  to  that  of  the  blood.  With  certain  ex- 
ceptions, to  be  afterward  considered,  these  additional  symptoms  render 
the  localization  of  the  source  of  the  hemorrhage  easy.     Thus,  when 


560 


FENWICK — DISEASES   OF   THE   URINE. 


pain  is  experienced  in  tlie  renal  organ*  tlie  diagnosis  is  at  once  con- 
fined to  those  diseases  of  tlie  kidney  wliicli  are  liable  to  evoke  hem- 
orrliage;  wliile  symptoms  of  irritability  of  tlie  bladder  and  obstruc- 
tion to  the  stream  of  urine  point  to  affections  of  the  lower  urinary 
tract. 

Bjematueia  Coexisting  with  Symptoms  of  Kenax,  Disturbance. 

In  dealing  with  symptomless  haematuria  it  was  shown  that  occa- 
sionally cases  are  met  with  in  which  blood  escai^es  freely  from  the 
renal  tissue  or  the  pelvis  without  any  pain  or  tenderness  being  ex- 
perienced by  the  patient  in  the  corresponding  loin.  In  the  majority, 
however,  of  renal  hemorrhages  j)ain  in  or  about  the  kidney  is 
also  present.  It  is  true  that  in  some  cases  the  pain  is  referred  to  the 
front  aspect  of  the  kidney  and  in  others  to  the  back ;  but  in  most  the 
patient  can  so  accurately  locate  the  pain  as  to  leave  the  practitioner 
in  no  doubt  as  to  the  organ  affected.  Moreover,  if  deep  pressure  be 
made  over  the  renal  region,  some  alteration  in  the  size  of  the  organ  f 
can  usually  be  made  out  in  favorable  subjects.  In  all  cases,  more  or 
less  marked  tenderness  on  pressure  is  present. 

The  diseases  most  commonly  met  with  belonging  to  this  group  are : 
Eenal  calculus,  tubercle,  chronic  nephritis,  and  malignant  disease. 

They  may  be  bracketed  as  under : 


Hsematuria 
preceded  or  ac- 
companied by 
pain  in  the 
kidney. 


,  Diurnal  frequency  of  mic- 
turition, if  present,  relieved 
by  rest ;  pus  in  later  stages. 
Blood  ceases  on  rest. 


■Stone  in  the  kidney. 


Frequency  marked  at  night ;  1 

pus  and  debris  passed  usually   [Primary    tuberculosis  of   the 
in    early    stages.     Blood  un-    |      kidney, 
affected  by  rest.  J 

!  Cystic  disease  of  the  kidney. 
Malignant  disease  of  the  kid- 
ney. 

There  is,  in  the  earlier  stages  of  renal  calculus  and  tubercle,  a  great 
similarity  in  the  symptoms  evoked  by  both  diseases,  so  much  so 
that  it  is  often  a  matter  demanding  acumen  and  experience  to  decide 
as  to  which  disease  is  present.  In  the  course  of  a  few  months,  how- 
ever, the  difiiculty  disappears,  for  characteristic  symptoms  develop. 


*  It  is  always  worth  the  trouble  to  strip  the  patient  and  to  be  certain  of  the  posi- 
tion where  pain  in  the  back  is  experienced— so  many  complain  of  a  pain  in  the  back 
which  is  not  actually  felt  in  the  renal  region,  but  which  is  the  result  of  rheumatic 
conditions  of  the  lumbar  fasciae  or  of  hepatic,  colonic,  or  prostatic  troubles. 

f  Pain  usually  means  tension  on  the  capsule,  and  this  again  accompanies  altera- 
tions in  size  and  shape  of  the  kidney. 


BUEMATURLAr  IN   RENAL  CALCULUS.  561 


Calculus  of  the  Kidney. 

The  hemorrliage  from  a  renal  calculus  does  not  possess  any 
marked  cliaracteristic  beyond  the  fact  that  it  is  affected  by  sudden 
movement  and  severe  exercise.  That  which  is  evoked  by  a  calculus 
imbedded  in  the  parenchyma  of  the  gland  may  have  occurred  once 
only  in  the  course  of  many  years,  and  the  circumstance  have  been  for- 
gotten— the  chief  feature  of  the  case  being  a  fixed  renal  pain.  But  the 
fallacy  of  basing  a  diagnosis  of  cortical  or  imbedded  stone  on  the  one 
symptom  of  fixed  pain  in  the  kidney  region  must  be  avoided.  I  have 
known  localized  renal  pain  with  healthy  urine  to  be  due  to  congestion 
of  the  liver  (post-mortem  case),  shrinkage  of  the  kidney  (operative 
case),  and  colonic  ulceration.  The  bleeding  which  is  produced  by  a 
stone  in  the  pelvis  or  in  some  deep  calyx  is  the  salient  feature  of  the 
disease  and  varies  in  character  and  amount  according  to  the  size  and 
surface  of  the  calculus,  its  position,  the  range  of  its  mobility,  and  the 
health  of  the  mucous  membrane  around  it. 

As  a  general  rule,  the  bleeding  in  pelvic  calculus  is  often  repeated, 
dependent  on  or  distinctly  increased  by  exertion.  It  is  rarely  x)ro- 
fuse,  the  color  is  never  very  bright,  and  the  blood  is  always  in- 
timately mixed  with  the  urine.  . 

Prout,"  who  was  an  excellent  and  trustworthy  observer,  says :  "  In 
plethoric  and  gouty  subjects  who  suffer  from  uric-acid  renal  concre- 
tions, the  blood  often  appears  in  the  urine  under  the  form  of  a  dark 
coffee-colored  sediment  mixed  with  uric-acid  gravel.  This  subsides 
after  a  time,  leaving  the  superjacent  urine  api^arently  little  colored. 
This  hemorrhage  is  sometimes  produced  by  very  slight  causes,  as,  for 
instance,  by  an  active  cathartic  which  has  been  taken  to  relieve  a 
bilious  attack.  Occasionally  the  blood  is  more  abundant.  Perhaps 
on  the  whole  renal  concretions  of  oxalate  of  lime  are  more  apt  to  pro- 
duce hemorrhage  than  any  other  variety.  Kenal  concretions  com- 
posed of  the  phosphates  are  sometimes  accomj)anied  by  bloody  urine, 
but  if  I  were  to  speak  from  my  own  experience  I  should  say  much 
less  frequently  than  some  other  forms  of  concretions." 

These  remarks  are,  I  believe,  mainly  correct,  but  nex)hrolithot- 
omy  has  taught  us  how  frequently  "  imbedded"  calculi  of  oxalate  of 
lime  exist  without  giving  rise  to  hsematuria.  As  a  general  rule,  the 
bleeding  will  l^e  found  to  occur  mostly  when  the  calculi  are  embraced 
by  mucous  membrane  and  to  vary  in  inverse  proportion  to  the  amount 
of  pyelitis.  Thus,  when  pus  is  passed  in  the  urine  in  decided  quan- 
tities, the  homfjrrhage  is  of  infrequent  occurrence  and  in  small 
amounts.  I  may  even  go  further,  and  state  that  hsematuria  due  to 
Vol.  I.— 36 


562  I^EFWICK — DISEASES   OF  THE  TJEINE. 

calculus  is  rarely  seen  wlien  a  pyoneplirotic  sac  has  been  formed.  It 
occurs  in  such  case  in  only  thirteen  per  cent.  * 

The  hemorrhage  which  follows  the  passage  of  a  small  stone  along 
the  ureter  is  transient  and  its  causation  obvious.  That  also  which 
accompanies  an  attack  of  renal  colic  without  the  passage  of  a  stone 
is  merely  due  to  congestion,  and  subsides  in  a  day  or  two. 

Typical  cases  of  renal  calculus  showing  how  much  the  hsematuria 
and  symptoms  depend  upon  the  proximity  of  the  stone  to  the  mucous 
membrane : 

A  Case  of  Renal  Stone  Imbedded  in  the  Cortex  of  the  Kidney  under 
the  Capsule  and  hence  Situated  at  a  Distance  from  the  Blucous  Membrane 
of  the  Pelvis. — J.  A.,  aged  30  (Dr.  Eastwood,  of  Darlington)  perfectly 
well  until  seven  years  ago  when  he  fell  on  to  his  back  on  the  ice  and 
ruptured  his  kidney  (query?)  and  passed  blood  for  fourteen  days,  but 
never  since.  From  this  date  he  has  had  a  dull,  heavy  pain  from  the 
back  of  the  kidney  to  the  front.  The  pain  never  radiates,  it  is  aggra- 
vated by  exercise  and  sometimes  "  sickens"  him.  He  has  no  frequency 
of  micturition.  The  stream  is  good,  it  never  suddeulj^  stops.  He  has 
never  passed  gravel.  Urine  normal  in  appearance ;  specific  gravity 
1.030;  acid;  oxalate  of  lime  crystals.  A  few  pus  cells.  Diagnosis 
cortical  oxalate  calculus.  Nephrolithotomy.  A  dark  oxalate  of  lime 
calculus  the  size  of  a  monkey-nut  was  removed  from  the  convex  sur- 
face of  the  kidney  by  merely  cutting  through  the  capsule.     Cure. 

A  Case  in  which  Stones  ivere  so  Deeply  Imbedded  in  the  Thickness  of 
the  Kidney  Substance  as  to  he  Unfeelable  through  the  Unbroken  Cortex. 
— Gr.  B.,  aged  52  (Dr.  Alec  Mackenzie,  of  Romford).  Pain  in  left 
kidney  came  on  suddenly  ten  years  ago ;  this  was  severe,  but  did  not 
radiate.  Since  then  the  pain  has  been  constant,  but  subject  to  ex- 
acerbation. Any  error  of  diet  or  exercise  increased  it.  Status 
prcesens — He  can  cover  the  "  pain  area"  with  his  thumb.  He  fre- 
quently passes  blood,  generally  of  a  coffee-color,  but  he  has  neither 
frequency  of  micturition  nor  pain  in  the  act.  Urine  1.022,  clear,  de- 
positing a  few  blood  and  pus  cells.  He  always  lies  on  the  affected 
side.  Nephrolithotomy  incision^a  collection  of  seven  stones  found 
encapsulated  in  centre  of  kidney  tissue — cured. 

Long  Pointed  Calcidus  Imbedded  in  Renal  Cortex,  but  ivith  its  Point 
Projecting  into  lower  Part  of  rencd  Pelvis. — T.  L.,  36  years  of  age  (Mr. 
John  Harris,  of  Dartmouth) .  Patient  complained  of  left  renal  pain, 
from  which  he  had  suffered  for  twenty  years.  He  could  cover  its 
position  with  the  last  phalanx  of  his  thumb.  It  could  be  elicited  also 
by  percussion  over  the  renal  region,  or  by  any  succussion  of  the  body. 
It  came  on  with  any  exertion,  even  with  walking.  The  patient  had 
never  had  colic  nor  any  radiating  pain  beyond  a  left  testicular  jjain 
if  the  renal  suffering  was  acute.  Sometimes  he  suffered  from  great 
frequency  of  micturition  in  the  day,  and  occasionally  had  to  rise  five 

*  It  will  be  found  that  tumors  of  the  kidney  containing  calculous  material  with 
pus  (calculous  pyelonephritis)  occur  usually  in  women  (in  the  proportion  of  5  to  1) , 
and  the  salient  symptoms  are  pain  and  constitutional  disturbance  rather  than  haema- 
turia.      ( Vide  Pyuria. ) 


H^MATURIA--IN   BENAL  TUBERCULOSIS.  563 

or  six  times  at  night,  passing  very  little  at  a  time.  He  had  never 
noticed  blood  in  his  urine.  Has  often  passed  gravel.  The  urine  was 
clear;  specific  gravity,  1.020;  it  contained  no  pus  or  blood,  and  only 
a  few  oxalate  crystals  were  visible  under  the  microscope ;  it  contained 
a  slight  amount  of  albumin.  By  nephrolithotomy  I  removed  a  rough- 
pointed  stone,  which  measured  1^  inches  in  length  and  weighed  1^ 
drachms.  It  was  imbedded  in  the  lower  end  of  the  kidney  and  its  nose 
projected  out  free  into  the  pelvis. 

Loose  Stone  in  Pelvis  Producing  backward  Pressm^e  Symptoms  and 
Infiammation  and  Evoking  Typical  Attacks  of  Benal  Colic. — W.,  aged 
52  (a  patient  of  the  late  Sir  Andrew  Clarli) .  Patient  had  suffered 
from  violent  recurrent  right  renal  colic  for  five  years.  At  first  the 
attacks  recurred  only  once  in  six  months,  but  the  interval  of  rest 
diminished,  until  finally,  when  he  consented  to  an  operation,  they 
were  taking  place  every  week. 

Each  attack  was  accompanied  by  numbness  in  the  back,  down  the 
inside  of  both  thighs,  and  in  the  calves  of  the  legs  and  testicles.  He 
had  passed  blood  several  times,  but  always  of  a  mahogany  color. 
The  patient  had  faithfully  followed  careful  instructions  as  to  diet,  and 
had  taken  courses  of  piperazine  without  any  effect.  Before  the  oper- 
ation the  urine  was  acid,  and  contained  one-sixth  albumin;  specific 
gravity,  1.010;  the  quantity  was  ample.  He  had  never  had  fre- 
quency of  micturition.  On  nephrolithotomy  a  small,  flat,  oval  uric- 
acid  stone  was  found  free  in  the  pelvis  and  removed.  The  pelvis 
was  much  dilated;  but  as  there  was  a  fair  amount  of  cortex  left,  the 
kidney  was  drained.  It  healed  sluggishly,  and  left  an  obstinate 
sinus,  which  remained  for  months. 

Cases  in  which  the  inflammation  was  so  far  advanced  as  to  pro- 
duce extreme  pyelitis  are  quoted  in  the  article  on  pj^uria. 

Primary  Chronic  Tuberculosis  of  the  Kidney. 

It  will  be  noted  that  primary  chronic  tuberculosis  only  is  dealt 
with  in  this  group,  the  reason  being  that  ascending  tuberculosis  in- 
vading the  kidney  secondarily  from  a  source  in  the  testicle,  prostate, 
or  vesiculge  seminales  is  ajjparent  and  diagnosable  by  touch.  Inva- 
sion from  these  sources  induces  pain  and  distress  in  the  bladder  in 
the  larger  number  of  cases  prior  to  implication  of  the  kidne3^  The 
attention  of  the  practitioner,  therefore,  is  directed  to  the  bladder, 
and  this  particular  region  is  considered  later  on.  Occasionally  the 
invasion  of  the  kidney  from  the  testicle  is  by  the  roundabout  route 
of  the  lymph  paths  which  lie  alongside  the  venous  channels  of  the 
testis,  ascending  to  their  termination  in  the  left  renal  vein  and  inferior 
vena  cava ;  these  not  only  mix  with  the  ureteral  vessels  but  also  not 
infrequently  receive  trunklets  which  drain  the  perirenal  fat  and  the 
capsule  of  the  kidney. 

Miliary  tubercles  irrupt  from  beneath  the  mucous  membrane  of 


564  FENWICK — DISEASES  OF  THE   UrilNE. 

the  renal  pelvis,  or  colonize  in  the  glomerular  zone  of  tlie  cortex.  As 
our  knowledge  increases,  we  may  be  able  perhaps  to  group  sepa- 
rately the  symptoms  evoked  by  the  deposit  in  each  of  these  differ- 
ently constructed  areas.  At  present  this  cannot  be  done  with  accu- 
racy, and  I  can  only  express  my  belief  that,  in  the  pelvic  form  of  the 
disease,  the  initial  symptoms  are  as  follows :  Blood  and  pus  appear 
in  small  amounts  in  the  urine,  either  coincidently  with  renal  pain  or 
very  soon  after  it  commences ;  the  stages  of  the  disease  are  passed 
through  more  quickly,  and  the  bladder — our  index  to  the  progress 
and  the  severity  of  urinary  tuberculosis — is  affected  earlier.  When 
the  deposit  is,  however,  situated  in  the  cortex,  it  has  to  break  into 
the  renal  pelvis  before  it  can  give  rise  to  characteristic  symptoms. 
Polyuria,  from  the  irritation  of  its  presence,  is  perhaps  the  symptom 
first  noticed  or  complained  of,  even  before  the  aching  in  the  kidney. 
The  urine  is  murky,  of  low  specific  gravity,  and  contains  albumin  over 
and  above  that  due  to  the  trace  of  pus.  The  hemorrhage  from  these 
two  positions  also  varies,  hence  perhaps  the  divergence  in  the  opinions 
of  writers  on  the  subject.  In  the  early  stage  of  x)elvic  ulceration  the 
bleeding  is  usually  slight  and  intermittent ;  when,  however,  a  cortical 
deposit  sloughs  out  suddenly  into  the  pelvis,  there  may  be  profuse 
and  dark  but  transient  hematuria. 

But  I  would  again  remark  that  the  hsematuria  in  primary  chronic 
tuberculosis  of  the  kidney  is,  I  believe,  only  a  feature  of  the  early 
stages ;  it  passes  away  more  or  less  rapidly,  and  gives  place  to  the 
passage  of  pus  and  clumps  of  caseous  debris,  and,  when  the  bladder 
is  fully  attacked,  to  vesical  bleeding. 

Difficult  as  is  the  loroj^er  allotment  of  the  symptoms  induced  by 
tuberculosis  of  the  kidney  and  the  bladder  to  their  respective  organs 
when  both  are  implicated,  I  am  probably  right  in  assuming  that 
hemorrhage  from  the  tubercular  bladder  is  much  more  abundant  and 
much  more  easily  evoked  by  cold  than  is  that  from  the  kidney. 

Tubercular  Deposit  on  the  Mucous  Memhrane  of  the  Rerml  Pelvis. — 
Mr.  Knowsley  Thornton"  records  the  following  case:  "All  the 
symjjtoms  were  those  of  calculus — pain  over  the  kidney  and  down 
the  ureter,  with  attacks  of  colic — then  hemorrhage,  and  finally 
profuse  suppuration  and  enlargement  of  the  kidney.  When  I 
opened  the  pelvis  I  found  its  lining  membrane  covered  with  little 
seed-like  tubercles  and  there  was  no  stone.  The  patient  was  imme- 
diately relieved  of  all  her  symptoms,  but  the  fistula  persisted,  and  the 
other  kidney  becoming  affected,  she  died  of  uraemia  seven  months 
after  the  operation.  The  post-mortem  revealed  extensive  tubercu- 
losis of  the  kidnej^  ojjerated  upon  and  of  the  rest  of  the  urinary 
organs — the  other  kidney  having  evidently  been  more  recently  at- 
tacked, and  probably  by  extension  up  the  ureter.     In  neither  kidney 


HJEMATURIA' IN  RENAL  TUBERCULOSIS.  565 

was  there  ulceration  or  caseous  deposit.  The  patient  was,  at  the 
time  I  operated  upon  her,  a  stout,  rosy  woman,  so  much  so  that  I 
should  have  doubted  her  statements  as  to  the  pains  she  suffered  had 
I  not  seen  her  actually  in  great  agony." 

Chronic  Tuberculosis  Commencing  Probably  in  the  Cortex  of  the 
Kidney  and  Invading  Bladder,  Prostate,  and  Testicle  Secondarily. — 
D.  J.,  33  years  of  age  (under  Dr.  Hilliard.)  Up  to  four  and 
a  half  years  previous  to  seeing  me  this  patient  was  in  perfect 
health.  He  had,  at  that  time,  an  attack  of  pain  in  the  right  side, 
which  was  called  by  his  doctor  renal  colic.  The  character  was  as 
follows :  Blood  appeared  in  the  urine  from  two  to  seven  days  before 
the  onset  of  the  attack;  it  came  in  clots,  and  often  the  bloody  urine 
was  very  red  with  much  bright  blood.  The  hsematuria  ceased,  and 
the  pain  then  seized  him  across  the  back,  and  coursed  down  the 
right  ureter  into  the  right  testicle.  He  vomited,  rolled  about  the 
bed  in  the  acuteness  of  the  agony,  and  passed  water  very  frequently, 
the  character  of  the  secretion  being  normal  to  the  eye.  These  symp- 
toms lasted  for  twenty-four  hours.     He  never  jjassed  a  calculus. 

These  attacks  of  renal  colic  continued  to  recur  at  intervals  of  two 
or  three  months,  becoming  latterly  more  frequent  and  more  severe 
until  eight  months  before  he  saw  me,  when  suddenly  all  symptoms 
ceased  in  the  kidney.  He  had  neither  kidney-ache  nor  severe  hfema- 
turia,  but  the  bladder  became  troublesome. 

Five  months  after  the  cessation  of  the  renal  pain,  he  had  to  get 
up  at  night  to  pass  water,  and  he  was  forced  to  emj)ty  his  bladder 
more  often  than  usual  in  the  day.  The  vesical  irritability  increased, 
pain  at  the  end  of  the  penis  after  micturition  set  in,  and  in  this  state 
and  with  this  history  he  came  under  my  care,  requesting  to  have  the 
stone  which  he  had  been  told  was  in  the  bladder  removed  as  soon  as 
possible. 

His  symptoms  were  as  follows : 

"  He  passes  water,  about  a  teacupful  at  a  time,  every  half-hour,  day 
and  night;  has  much  glans  pain  after  micturition.  If  blood  is  seen, 
it  is  intimately  mixed.  There  are  no  testicular  deposits ;  no  prostatic 
deposit,  but  the  right  side  of  the  bladder  base  feels  shotty.  No  renal 
tumor,  but  there  is  a  tenderness  over  the  right  kidney.  Urine  con- 
tains pus;  tubercle  bacilli  have  been  found;  specific  gravity  is  1.010." 

Electric  Cystoscopy. — "Bladder  only  holds  three  ounces.  There 
is  no  stone.  The  mucous  membrane  of  the  base  is  turgid,  dark- 
red,  and  spongy,  like  that  of  an  exposed  rectum.  The  rest  of  the 
bladder  is  either  coated  over  with  adherent  patches  of  dull  whitish 
pus,  situated  on  an  inflamed,  purple,  succulent  mucous  membrane,  or 
is  ulcerated.  These  white  patches  seem  to  be  the  boundaries  of 
large  superficial  erosions  of  the  surface.  They  have  a  fleecy  base, 
and  evidently  rest  on  the  submucous  tissue.  The  ureteral  orifices 
are  puffy,  more  especially  the  right.  There  is  much  pain  on  instru- 
mentation. Even  when  deeply  under  chloroform  he  flinches  and 
moans  on  any  slight  over-distention,  i.e.,  anything  over  three  ounces." 
The  diagnosis  of  descending  tuberculosis  was  made,  and  Dr.  Hilliard 
was  warned  of  the  probable  implication  of  the  right  testis  and  right 
lobe  of  the  prostate,  which  took  j)lace  three  months  after,  this  exam- 


566 


FENWICK — DISEASES  OF  THE  URINE. 


ination.  Since  then  I  liave  had  this  patient  under  close  observation 
for  eighteen  months;  the  left  epididymis  is  now  affected.  Several 
collections  of  pus  (chronic  abscesses)  have  formed  under  the  skin  of 
the  forearm  and  thigh.  The  testicular  deposit  on  the  right  side 
came  to  the  scrotal  surface  and  was  opened,  as  were  the  other  ab- 
scesses, and  scraped,  iodoform  being  packed  into  the  suppurating 
cavities.  He  now  passes  water  every  half -hour  in  the  day  and  every 
three-quarters  of  an  hour  at  night;  his  legs  are  oedematous,  his 
sufferings  great,  and  I  doubt  if  he  will  live  much  longer.  It  is  now 
six  years  since  the  onset  of  the  symptoms. 

Differential  Diagnosis  between  Stone  and  Tubercle  of  the  Kidney. — 
Our  capacity  for  differential  diagnosis  here,  as  in  other  and  similar 
problems  in  urinary  surgery,  will  depend  much  upon  our  skill  in 
cross-examining  as  to  the  initial  symptoms,  and  upon  our  due  appre- 
ciation of  the  nature  and  intensity  of  the  irritation  which  has  pro- 
duced them.  We  recognize  that  in  stone  we  are  dealing  with  a  for- 
eign body  confined  more  or  less  loosely  in  a  sensitive  space,  and 
dependent,  therefore,  for  its  power  of  inflicting  injury  (as  evidenced 
by  the  blood  and  pus  in  the  urine)  upon  the  exercise  which  the  pa- 
tient takes.  On  the  other  hand,  we  realize  that  in  tubercle  we  are 
grappling  with  one  or  more  foci  of  short-lived  tendencies,  and  there- 
fore prone  to  produce  purif orm  urine ;  that  these  foci  possess  caustic 
and  continuous  irritative  properties,  which  place  them  beyond  the 
calmative  control  of  posture  or  of  bodily  rest.  I  believe  that  the  best 
indications  for  the  diagnosis  of  renal  tubercle  are  to  be  found  in  the 
family  history  of  the  patient ;  in  the  appearance  of  pus  in  the  urine 
very  soon  after  if  not  coincidently  with  the  renal  pain ;  in  the  power- 
lessness  of  absolute  rest  to  affect  or  subdue  the  symptoms,  and  in  the 
causeless  elevation  of  the  evening  temperature. 

Other  differences,  however,  exist,  and  an  attempt  may  be  made 
to  tabulate  them  thus : 


Primary  Benal  Tubercle  in  Early  JStage. 
Family  history  of  phthisis  or  cancer. 

Personal  history :  Perhaps  tuberculous 
bone-,  joint-,  or  gland -disease  ;  very 
rarely  any  previous  urinary  or  lung 
symptoms. 

Symptoms,  onset :  Polyuria  of  a  murky 
type  (the  frequency  of  micturition  be- 
ing due  to  the  quantity  passed,  not  to 
irritation) ,  vague  lumbar  pain  or  a  sud- 
den chill,  and  severe  pain  in  one  kid- 
ney, but  rarely  colic.  Then  frequency 
of  micturition  in  the  early  stages  at 
night  fronu  irritation  of  acrid  urine. 


Renal  Stone  in  Early  Stage. 

Family  history  negative,  or  of  gout  or 
gravel. 

Personal  history  :  Negative,  except  per- 
haps the  passage  of  sand  or  gravel ;  of 
a  "  weak  "  loin  ;  of  testicular  neuralgia 
or  "  sciatica.  " 

Symptoms,  onset :  Vague  lumbar  aching 
or  a  sudden  colic.  If  frequency  of 
micturition  exist  it  is  due  to  irritation  ; 
small  quantities  are  passed  often  dur- 
ing the  day,  but  not  at  night.  This  is 
relieved  by  rest. 


HiEMATURIA   IN   CYSTIC  DISEASE   OP  THE   KIDNEY. 


567 


Primary  Renal  Tubercle  in  Early  Stage. 

Colics  appear  later,  are  usually  less  se- 
vere, are  more  easily  under  the  control 
of  drugs,  do  not  usually  retract  the 
testicle,  and  are  preceded  by  rose-red 
blood  if  they  are  induced  by  ulceration 
and  not  by  blockage. 

Haematuria :  Slight  in  amount,  sponta- 
neous in  appearance,  uninfluenced  by 
rest. 

Fever :  Temperature  may  be  slightly 
raised  at  night. 

Urine :  Cloudy  at  the  outset  from  ad- 
mixture of  mucus  and  pus,  acid,  of  low 
specific  gravity,  light-colored,  de- 
positing a  thin  layer  of  pus  with 
streaks  of  blood,  debris  of  connective 
tissue  and  small  clumps  of  caseous  ma- 
terial.    Albumin  appears  early. 

Tubercle  bacillus  found,  but  with  diffi- 
culty and  after  much  search  in  acid 
urine. 

Inoculation  of  urine  deposit  into  animals 
induces  tuberculosis. 

General  condition  :  Patient  ailing,  "  never 
feels  well,  "  isanajmic,  easily  tired,  but 
has  no  loss  of  appetite.  Sometimes  a 
strumous  fades. 


Benal  Stone  in  Early  Stage. 
Colics  :   More  or  less  severe  according  to 
composition  and  size  of  stone,  and  its 
position.       They  may  be  followed  by 
bleeding. 


Haematuria  :  Intimately  mixed  ;  much 
more  marked  than  in  tubercle  depend- 
ent on  exercise. 

Fever :  None. 

Urine  :  Clear  at  outset,  containing  evi- 
dences of  calculous  tendencies  in  the 
shape  of  crystals,  acid,  of  normal  spe- 
cific gravity.  Pus  appears  later  in 
course  of  case,  and  then  only  forming  a 
deposit  when  pyelitis  has  been  induced. 


Negative. 


Negative 

General  condition  :  Patient  may  enjoy 
excellent  health  between  colics  or  in 
intervals  of  rest. 


Cystic  Benal  Disease. 

It  lias  been  remarked  in  discussing  the  symptomless  haematurias 
tliat  some  cases  of  chronic  renal  disease  bleed  smartly  and  pain- 
lessly. There  is  no  doubt,  however,  that  occasionally  hemorrhage 
from  this  source  is  accompanied  by  pain;  and  in  some  of  these  I 
have  found  definite  cystic  conditions  of  the  kidneys. 

Case. — I  was  called  on  July  6th,  1894,  to  see  a  man,  aged  31,  by 
a  physician  who  desired  me  to  perform  some  operation  for  his  relief. 
The  patient  was  blanched  by  profuse  hematuria ;  had  scar  evidences 
of  having  suifered  from  severe  secondary  syphilis;  his  urine  was 
loaded  with  casts  and  albumin,  and  showed  a  specific  gravity  of 
1.009.  Both  kidneys  were  tender  on  deep  pressure.  His  history 
was  as  follows:  A  year  previously  he  had  had  a  sharp  attack  of 
haematuria  accompanied  by  pain  in  the  right  side.  On  July  1st, 
1894,  he  was  suddenly  seized  with  great  pain  in  the  region  of  both 
kidneys,  and  in  twenty-four  hours  bright  blood  appeared  in  the  urine. 
The  amount  of  blood  varied  from  a  mere  trace  to  an  almost  pure  con- 
dition. He  urinated  ten  times  in  twenty-four  hours  and  passed  60  to 
107  ounces  daily.     On  July  5th,    the    urine  being  then  clear,    the 


568  FENWICK — DISEASES  OF  THE  URIKE. 

physician  introduced  a  Pravaz  syringe  into  the  left  kidney  and  a 
syringeful  of  pure  blood  was  withdraw.  About  fifteen  minutes  after- 
ward the  patient  passed  fourteen  ounces  of  blood  per  urethram,  ac- 
comxjanied  by  severe  pain  in  the  left  side.  The  haematuria  continued, 
diarrhoea  appeared,  and  a  rigor  took  place  a  week  after  the  explora- 
tion. I  declined  to  interfere  by  operation,  and  the  patient  died  on 
the  tenth  day  after.  On  post-mortem  both  the  kidneys  were  found  to 
be  enormous  and  transformed  into  a  conglomerate  mass  of  multi- 
locular  cysts,  probably  of  congenital  origin. 


Malignant  Disease  of  the  Kidney. 

I  have  already  expressed  my  belief  that  the  onset  symptom  in  the 
majority  of  cases  of  malignant  disease  of  the  kidney  is  hsematuria, 
also  that  renal  pain  is  not  at  first  experienced.  The  consideration  of 
this  disease,  therefore,  fell  into  the  group  of  symptomless  hsema- 
turias.  But  I  am  not  supported  in  this  statement  by  the  literature 
of  the  subject,  which  represents  the  pain  as  being  of  quite  a  marked 
character  at  the  outset,  *  and,  moreover,  I  am  aware  of  several  cases  in 
which  pain  either  preceded  the  hemorrhage  when  the  growth  was 
very  rapid,  or  a  calculus  pre-existed.  In  two  cases  the  pain  was 
obviously  induced  by  the  practitioner  lighting  up  acute  suppurative 
nephritis  by  his  examination.  It  is,  therefore,  necessary  briefly  to 
allude  to  maligant  disease  of  the  kidneys  under  this  group  also.  , 

Case. — 3Ialignant  Disease  of  Kidney  ivith  Fain  in  affected  Loin, 
dueprohahly  to  Tension  on  the  Capsule  of  the  Organ."" — M.  X.,  aet.  50, 
consulted  M.  Reliquet  in  December,  1884,  for  urinary  trouble.  His 
history  was  as  follows.  For  many  years  he  had  suffered  from  neph- 
ritic colic  accompanied  by  haematuria,  and  "voided  uric-acid  gravel. 
After  i^assing  in  1881  a  larger  piece  of  calculus  than  usual,  he  re- 
mained well  until  October,  1884,  when  he  again  had  an  attack  of 
nephritic  colic.  Toward  the  20th  of  October  of  this  year,  fever, 
rigors,  headache,  anorexia,  and  frequent  micturition  appeared.  The 
urine  had  a  strong  odor,  was  muco-jmrulent,  but  abundant.  No  renal 
tumor  could  be  felt  at  this  time  on  the  left  side,  where  pain  was 
complained  of,  but  in  the  early  part  of  December  a  tumor  the  size 
of  a  large  apple  was  discovered  in  this  region.  It  was  painful  on 
pressure,  slightly  movable,  and  was  considered  to  be  a  hydro- 
nephrosis by  the  medical  attendant. 

The  xjatient  now  consulted  M.  Reliquet,  who  found  a  left  renal 
tumor  the  size  of  an  infant's  head,  without  bosses  or  soft  points. 
The  urine  was  scanty,  murky  with  jjurulent  deposit,  ammoniacal, 
and  very  fetid.     There  was  extreme  irritability  of  the  bladder,  a  few 

*  I  cannot  help  thinking  that  insufficient  attention  has  been  paid  to  the  onset 
symptoms.  It  is  true  that  clot  colic  is  pain,  but  then  the  cause  of  this  is  transient 
and  the  patient  does  not  suffer  until  another  clot  is  plugging  the  ureter  or  urethra. 


HEMATURIA  IN   MALIGNANT  DISEASE  OP  THE  KIDNEY.  569 

drops  of  urine  only  could  be  voided  at  a  time,  with  much  suffering 
experienced  both  before  and  after  the  act.  The  patient  demanded  to 
be  released  from  the  excessive  and  recurrent  pain  of  nephritic  colic 
and  strangury. 

M.  Eeliquet,  believing  that  he  would  not  live  much  longer  in 
such  extreme  suffering,  performed  lumbar  nephrotomy  by  means  of 
the  ther mo-cautery.  When  the  renal  tumor  was  laid  bare,  it  was 
punctured  with  the  thermo-cautery,  and  on  withdrawing  the  point 
a  jet  of  blood  shot  out  from  the  opening  with  such  great  force 
that  it  passed  over  the  operator's  shoulder.  The  finger  was  inserted 
into  the  kidney,  and  it  was  then  found  that  the  tumor  was  extremely 
soft  and  friable,  so  much  so  that  when  an  attempt  was  made  to  enu- 
cleate the  kidney  it  broke  down  under  the  fingers  in  all  directions. 
The  operator,  after  tearing  away  as  much  as  possible  of  the 
renal  mass,  arrested  the  profuse  hemorrhage  by  means  of  sponges 
packed  into  the  wound. 

The  patient  was  immediately  relieved  of  all  pain  in  urinating,  the 
vesical  irritability  subsided,  the  nephritic  colic  ceased,  and  the 
urine  augmented  in  quantity.  Neither  nausea  nor  vomiting  reap- 
peared, the  patient  was  able  to  take  food  with  great  comfort,  and 
indeed  pronounced  himself  "cured."  In  spite,  however,  of  this  re- 
markable result  of  the  operation,  the  growth  progressed,  and  the 
patient  died  two  months  afterward. 

Case. — Acute  Malignant  Gn^oivth  of  Kidney. — Clot  Retention,  Catlie- 
terismand  Washing. — Acute  Suppurative  Nephritis. — Great  Renal  Pain. 
— J.  S.,  set.  60.  Two  months  before  death  the  patient  thought  he 
had  caught  cold  in  his  kidneys  because  he  suddenly  passed  bright 
blood.  He  was  placed  upon  iron  and  ergot,  but  no  improvement 
followed,  and  he  began  to  pass  many  worm-like  clots.  There  was  no 
renal  colic,  nor  tenderness  on  deep  pressure  in  either  renal  region. 
The  prostate  was  enlarged  antero-posteriorly  and  laterally.  Under 
the  use  of  hazeline  and  with  the  enforcement  of  rest  the  blood  began 
to  diminish,  and  in  a  week's  time  it  had  ceased.  The  patient  then  be- 
gan to  suffer  from  pain  in  the  left  loin,  and  was  unable  to  make  water. 
A  No.  12  English  silver  catheter  was  passed,  and  thirty  ounces  of 
dark-colored  urine  and  clots  were  evacuated.  Retention  continued 
and  almost  pure  blood  was  evacuated.  The  bladder  was  washed  out 
with  hazeline  and  a  solution  of  boracic  acid.  The  pain  in  the  kid- 
ney now  became  very  severe,  the  retention  ceased,  the  temperature 
began  to  rise,  then  to  oscillate,  and  the  patient  died  three  weeks 
after  the  vesical  treatment  was  commenced.  On  post-mortem  ex- 
amination a  large  kidney  with  scattered  deposits  of  soft  carcinoma  was 
found,  the  unimplicated  renal  tissue  being  in  a  state  of  acute  nephritis. 
The  fellow  gland  was  also  affected  with  inflammation. 

I  believe  that  in  this  case  urethral  fever  or  slight  cystitis  (follow- 
ing on  clot  retention,  and  the  passage  of  a  catheter  and  the  manipu- 
lation necessary  to  evacuate  the  clots)  induced  the  pain  and  the  fatal 
result;  for  fever  ai)ijeared  directly  upon  the  interference  and  the  pa- 
tient's condition  changed  at  once  and  for  the  worse. 


570 


FENWICK — DISEASES   OF  THE  UEINE. 


HEMATURIA    COEXISTESfG    WITH    SYMPTOMS    DENOTESfa    DISEASE  IN  THE 

LowEE  Ueinaey  Oegajsts. 

The  class  in  which  symptoms  such  as  frequency  of  micturition, 
obstruction  to  the  stream,  and  pain  in  the  urethra,  siiprapubic  region, 
or  perineum,  precede  the  appearance  of  blood  in  the  urine,  comprises 
most  of  the  diseases  of  the  bladder  and  urethra.  The  diagnosis  is, 
however,  in  the  majority  of  instances,  comparatively  easy.  Every 
method  of  examination,  the  urethral  bougie,  the  calculus  sound,  the 
catheter,  must  be  resorted  to  for  the  differential  diagnosis. 

These  diseases  may  be  bracketed  as  under,  but  only  those  calling 
for  special  mention  need  be  alluded  to. 


Hsematuria 
preceded  by 

vesical 
irritability. 
Pain  in  the 

urethra, 

especially  at 

the  glans  on 

urination. 

Pain  in 
other  locali- 
ties, indicat- 
ing a  vesical 
or  prostatic 

origin. 
Obstruction 

to  the 

stream. 


a.  Child- 
hood to 
young 
adult 
life. 


b.  Adult 

life  up  to 

fifty.* 


c.  Old 


Vesical  irritability ;  pain 
and  blood,  subsiding  on 
rest. 

Frequency  of  micturition  I 
diurnal.  Obstruction  toj 
stream  slight. 

Frequency  nocturnal  as  well  f 
as  diurnal,  unaffected  by  J 
rest  except  in  the  earliest  | 
stages.  [ 

Evidence  by  bougie.  j 

Evidence  by  soimd.  ] 

Evidence  per  rectum. 

Evidence  per  rectum  and 
by  sound,  etc. 


1.  Stone  in  the  bladder. 

2.  Prostatic  troubles  due 
to  gonorrhoea  or  onan- 
ism. Benign  growth 
at  vesical  orifice. 

3.  Catarrhal  or  primary 
tubercular  ulceration  of 
bladder.  Tubercle  of 
prostate. 

4.  Stricture  and  cystitis. 
Hemorrhagic  cystitis. 

5.  Calculus;  calculous 
cystitis. 

6.  Infiltrating  carcinoma 
away  from  orifice.  Pro- 
static carcinoma. 

7.  Stone  in  the  bladder. 

8.  Prostatic  enlargement. 


Stone  in  the  Bladder. 

The  symptoms  of  stone  in  the  bladder  need  not  be  discussed  in 
detail.  In  the  child  and  young  adult  they  are  especially  marked,  be- 
cause there  is,  at  these  ages,  no  prostatic  enlargement  which  can 
prevent  the  calculus  from  falling  upon  the  sensitive  neck  of  the  blad- 
der and  from  eliciting  those  symjDtoms  which  we  recognize  as  char- 
acteristic of  the  disease.    In  the  less  sensitive  bladder  of  the  aged  the 


*  This  subdivision  into  groups  marked  by  the  ages  of  the  patients  is  neither  scien- 
tific nor  accurate.  It  is  convenient  only,  for  it  serves  to  remind  one  that  the  age  of 
the  patient  is  often  a  useful  guide  to  the  character  of  the  complaint.  Thus  stone, 
though  occurring  at  every  age,  is  most  common  before  puberty  and  after  55  (Sir  H. 
Thompson) .  Stricture  generally  arises  before  35 ;  inflammatory  prostatic  disease 
between  20  and  30 ;  benign  growth  of  the  bladder  between  20  and  40 ;  malignant 
growth  of  the  bladder  is  most  common  before  10  and  after  45  ;  senile  prostatic  en- 
largement about  48  and  onward. 


H^MATUEIA   IN -DISEASE   OF   THE   BLADDEE.  571 

stone  may  be  lodged  behind  tlie  upraised  prostate,  and  tlius  be 
"latent"  or  symptomless,  except  for  the  cystitis  it  produces.  In 
some  of  these  cases,  as  I  remarked  when  considering  the  symptomless 
hematurias,  blood  after  exercise  is  the  only  symptom  noticed,  but  the 
urine  is  soon  found  to  contain  traces  of  pus  or  mucus. 

The  hemorrhage  of  calculus  in  ninety-three  per  cent,  of  my  cases 
was  preceded  by  that  feeling  of  irritation  which  a  foreign  body  excites 
in  a  cavity  sheathed  by  sensitive  mucous  membrane  and  surrounded 
by  muscle,  viz.,  by  involuntary  sj^asmodic  contractions,  and  by  a  con- 
stant desire  to  urinate.  These  symptoms  are  soon  followed  by  pain 
at  the  end  of  the  penis  on  micturition,  and  a  teasing  sensation  that 
the  bladder  has  not  been  thoroughly  emptied.  Attacks  of  cystitis 
supervene  and  blood  appears.  It  is  to  be  noted,  however,  that  when  tlie 
catheter  is  habitually  used  and  the  prostate  is  ujjraised,  the  symptom 
which  is  characteristic  of  stone  is  not  blood  but  pain  on  movement. 

Calculous  Cystitis. — This  is  a  fitting  opportunity  to  remind  the  reader 
that  cases  are  met  with  in  which  the  hemorrhage  persists  even  after  a 
skilful  litholapaxy.  The  spongy  mucous  membrane  still  bleeds,  and 
the  patient  has  suspicions  that  some  fragments  have  been  left  behind 
by  the  operator.  This  does  undoubtedly  happen,  but  there  are  blad- 
ders which  still  ooze  although  all  grit  has  been  removed.  In  some 
'  of  these  cases  it  will  be  found  that  phosphate  of  lime  adheres  to  the 
inflamed  surface  in  patches,  and  that  when  these  deposits  scale  off 
the  bleeding  and  irritation  cease. 

I  have  seen  two  patients  lately,  in  whom  a  calculus  had  been 
crushed  by  one  of  the  best  European  lithotritists,  but  in  whom  the 
hemorrhage  continued.  On  returning  to  their  surgeon  they  were 
told  that  they  were  suffering  from  a  growth  in  the  bladder.  I  was 
subsequently  asked  to  examine  with  the  cystoscope,  in  order  to  con- 
firm or  rebut  the  diagnosis.  In  each  case  I  saw  merely  an  intensely 
congested  spongy  mucous  membrane,  and  by  administering  a  little 
port  wine  to  the  patients  and  sending  them  to  the  seaside,  the  hem- 
orrhage vanished. 

Case. — Calculus,  Chronic  Cystitis,  Lithotrity,  Hcematuria. — M., 
set.  59,  consulted  me  for  hsematuria.  His  history  was  as  follows: 
In  March,  1885,  lithotrity  was  performed  for  a  small  angular  phos- 
phatic  calculus.  The  amount  of  blood  which  then  appeared  in  the 
urine  depended  upon  the  amount  of  exercise  taken.  Since  this  opera- 
tion he  has  suffered  more  or  less  from  catarrh  of  the  bladder,  which 
increased  greatly  in  December,  1888.  The  patient  has  always 
had  very  irritable  mucous  membranes,  his  throat  and  stomach  fre- 
quently becoming  inflamed  upon  any  sudden  increase  of  mental  work 
or  worry.  In  January,  1889,  he  commenced  to  pass  blood,  and 
continued  to  do  so  without  intermission  for  five  months.     The  urine 


572  FENWICK — DISEASES  OF  THE  UEINE. 

was  of  a  dark-brown  color,  the  blood  being  uniformly  mixed,  the 
amount  of  blood  being  greater  at  night.  He  suffered  no  pain,  and  only 
occasional  irritability.  On  examination  I  found  that  the  prostate  was 
not  enlarged,  that  no  residual  urine  was  present,  that  the  stream  was 
full  and  forcible,  never  intermitting.  On  cystoscopy  no  tumor  nor 
growth  was  visible ;  the  mucous  membrane  was  swollen  and  gelatinous 
in  every  part,  and  of  a  dark,  dull  purple  color.  Evidently  the  blood 
was  oozing  from  many  points.  The  injection  of  warm  water  irritated 
the  bladder  greatly,  and  he  passed  an  increased  quantity  of  blood  for 
a  few  hours  after  the  examination.  This  excess,  however,  rapidly 
subsided.     He  was  eventually  cured  by  change  of  air. 

Benign    Vesical   Growths    so    Situated   as    to    Obstruct    the    Urethral 
Orifice  of  the  Bladder. 

Yillous  papillomatous  growths  of  the  bladder,  which  either  fall 
upon  the  urethral  orifice  or  grow  around  that  outlet,  differ  from 
other  benign  growths  of  the  bladder  by  provoking  symptoms  of 
vesical  irritability  and  obstruction  to  the  stream,  prior  to  the  hem- 
orrhage. Such  tumors  number  eight  per  cent,  of  all  villous  papillo- 
mata  and  have  peculiar  dangers  attached  to  them. 

Typical  Case. — A  hng-j)edicled,  Villous  FopUloma  Ohstnicting 
Urethral  Orifice  of  Bladder. — Mr.  A.  S.,  aged  24  (under  Dr.  Keser). 
He  was  blanched  and  breathless  from  loss  of  blood.  He  gave  me  the 
following  account  of  his  case :  A  year  ago  he  was  suddenly  seized 
with  a  desire  to  pass  water  frequently.  There  was  slight  difficulty 
in  doing  so,  but  no  pain.  Blood  appeared  about  a  week  later,  and  all 
symptoms  subsided.  In  fourteen  days'  time  he  had  a  precisely 
similar  attack  and  since  then  he  has  suffered  for  an  entire  year  from 
irritability  of  the  bladder  and  ha^maturia.  He  has  been  unable  to 
hold  his  water  for  more  than  two  hours  unless  in  bed,  from  which  he 
rises  twice  in  the  night.  The  first  part  of  the  stream  is  dark  blood, 
the  middle  is  clearer,  and  the  last  portion  bright  blood.  The  stream 
is  slow,  powerless,  and  thin.  It  shoots  out  at  the  commencement 
with  some  little  force ;  then  it  stops  abruptly,  especially  if  he  has  re- 
tained water  longer  than  u^sual.  He  has  a  slight  aching  in  the  right 
loin.  Electric  cystoscopy  revealed  a  large  papilloma,  attached  by  a 
pedicle  to  the  rim  of  the  right  ureteral  orifice.  Suprapubic  cystotomy 
was  immediately  performed  and  the  pedicle  dissected  out  of  its  muscle 
bed,  which  latter  was  sound.  '    Recovery  followed. 

The  particular  danger  to  which  these  corking  growths  expose 
the  patient  is  septic  pyelonephrosis  arising  from  the  examina- 
tion. I  have  always  found  much  residual  urine,  as  well  as  evidence 
that  backward  renal  pressure  has  been  exerted  on  one  or  both  kidneys 
in  these  cases.  The  cystoscopic  examination  entails  washing,  and  if 
an  operation  is  not  immediately  performed  and  the  bladder  drained, 


HEMATURIA   IN..JDISEASE   OF   THE   BLADDER.  573 

cystitis  from  introduction  of  organisms  to  the  residual  pool  may  take 
place  and  pyelitic  and  nephritic  complication  ensue. 

Tuhercular  Ulceration  of  the  Blxidder. 

The  symptoms  of  primary  tuberculosis  of  the  bladder  are  very 
characteristic.  They  are  nearly  always  thought  at  first  to  be  due  to 
stone,  though  the  differences  are  marked.  A  young  male,*  sixteen 
to  twenty -five  years  of  age,  often  without  any  venereal  history  but 
with  a  family  tendency  (usually  maternal)  to  tubercle,  suddenly  ex- 
periences a  pain  in  the  glans  or  mid-penis  while  urinating.  There  is 
an  almost  immediate  increased  frequency  of  micturition  in  the  day. 
In  76  per  cent,  of  my  cases,  frequency  of  micturition  and  penile  pain 
were  the  first  symptoms  noticed,  but  in  the  smaller  number,  in  which 
I  suspect  a  vesical  deposit  secondary  to  some  extra-urinary  tubercu- 
lar focus  sloughed  out,  hemorrhage  was  the  onset  symptom.  Soon 
the  night  is  much  disturbed  by  constant  calls  to  empty  the  bladder. 
These  symptoms  are  followed  in  a  variable  time  according  to  the 
acuteness  of  the  disease,  from  a  few  days  to  a  few  months,  by  the 
appearance  of  blood  in  the  urine.  The  blood  is  often  profuse  and 
very  bright  at  one  time  or  other  in  the  course  of  the  early  stage,  from 
sloughing  out  of  the  deposits ;  but  these  attacks  are  for  the  most  part 
transitory,  and  the  patient  usually  only  sees  a  few  drojjs  of  blood 
follow  the  end  of  the  stream  of  urine,  strained  out  as  it  were  by  his 
efforts  to  get  rid  of  "something."  The  stream  of  urine  is  often  ar- 
rested, but  if  the  cause  for  this  is  inquired  into  carefully,  it  will  be 
ascertained  that  the  patient  checks  it  voluntarily  on  account  of  the 
spasm  and  pain.  The  sudden  cessation,  therefore,  is  not  due  to  the 
abrupt  plugging  of  the  urethral  orifice  with  a  stone.  After  a  few 
months  the  bladder  becomes  contracted,  so  that  it  cannot  contain 
more  than  6  to  8  ounces,  and  if  the  surgeon  forces  in  more  by  means 
of  a  syringe,  "  the  distention  reflex"  is  so  great  that  the  patient  will 
often  kick  or  groan  even  when  all  corneal  sensation  has  been  abol- 
ished by  ether.  The  urine  from  the  very  first  contains  traces  of  pus, 
and  this  increases  rapidly  to  a  thin  but  distinctly  visible  deposit. 
The  secretion  is  more  or  less  murky,  of  a  light  color,  of  normal  speci- 
fic gravity,  and  it  remains  feebly  acid  or  neutral  until  the  surgeon 
makes  it  alkaline  by  interference.  At  first  there  are  well-marked 
periods  of  quiescence,  often  for  a  fortnight  or  more  at  a  time,  and  in 
these  periods  the  irritability,  pain,  and  blood  disappear,  or  nearly 
so.     It  will  be  noted  how  readily  the  bleeding  is  re-started— a  few 

*  A  young  male  is  taken  as  a  type,  but  the  young  girl,  though  not  equally  liable 
to  the  disease,  presents  a  similar  train  of  symptoms. 


574  FENWICK — DISEASES   OF  THE  UKINE. 

hours  after  an  extra  exertion,  or  a  sudden  cliill  to  the  body,  as  in 
bathing  or  getting  wet,  a  sharp  attack  of  hemorrhage  takes  place, 
clots  and  bright  blood  being  freely  passed.  To  a  superficial  observer 
the  early  symptoms  of  primary  vesical  tuberculosis  are  very  like 
those  of  stone  in  the  bladder.  The  same  irritability,  the  same  glans 
pain  after  urination;  the  blood,  pus,  and  murky  urine;  the  stop- 
pages in  the  stream,  and  the  periods  of  quiescence  appear  in  both 
diseases.  There  are,  however,  points  of  difference  in  the  patient,  in 
his  symptoms,  and  in  his  urine,  which  will  at  once  lead  to  the  exis- 
tence of  stone  being  doubted.  His  youth,  his  family  history ;  the 
distressing  irritability  of  the  bladder  at  night ;  the  sudden  and  cause- 
less apiaearance  of  bright  hsematuria  not  increased  by  exercise  nor 
checked  by  rest ;  the  sudden  relief  of  the  suprapubic  pain  and  the 
rapid  disapj)earance  of  the  glans  pain  after  the  evacuation  of  the 
bladder;  the  persistent  post-scrotal  pain;  the  very  light,  acid, 
murky,  scentless,  puriform  urine  which  is  passed  at  the  very  outset 
of  the  trouble ;  and  finally,  the  fact  that  the  periods  of  quiescence  are 
uninfluenced  by  violent  exercise,  point  to  the  tuberculous  and  not  to  a 
calculous  nature  of  the  disease. 

The  progress  of  the  case,  however,  will  probably  dispel  any  doubt, 
for  the  epididymis  will  become  implicated,  and  the  prostate  will  then 
be  felt,  per  rectum,  knobby  or  shotty  from  the  deposition  of  tubercle ; 
or  the  kidney  will  become  painful  and  swollen  and  the  temperature 
will  rise  at  night.  If  an  incision  is  made  into  the  kidney,  a  quantity 
of  inodorous  caseous  pus  will  be  evacuated,  to  the  great  relief  of  the 
patient  and  the  amelioration  of  the  bladder  symptoms. 

Stricture. 

It  but  rarely  hapj)ens  that  bleeding  occurs  in  stricture  of  the  ure- 
thra apart  from  instrumentation. 

The  hgematuria  which  sometimes  appears  spontaneously  in  stric- 
ture is  usually  from  the  neck  of  the  bladder,  and  is  strained  out  by 
the  patient  from  the  congested  mucous  membrane  lining  that  orifice. 
The  vessels,  especially  the  veins,  of  the  neck  of  the  bladder  are  fre- 
quently seen  by  means  of  the  cystoscope  to  be  large  and  tortuous  in 
tight  stricture,  and  in  those  cases  in  which  spontaneous  hemorrhage 
has  occurred,  large  and  distinct  extravasations  are  seen  in  the  lower 
part  of  the  posterior  wall.  There  is  no  doubt,  however,  that  the 
hemorrhage  may  proceed  from  granular  kidney  which  in  rare  in- 
stances coexists  with  stricture.  In  all  cases  of  spontaneous  hemor- 
rhage in  stricture  there  must  have  been  very  decided  narrowing  and 
marked  obstruction  to  the  stream. 


H^MATUEIA  DUETTO  ENLAKGED  PROSTATE.  575 

The  Hmmaturia  of  the  Senile  Enlarged  Prostate. 

Tlie  sponge-like  tissue  of  tlie  enlarged  prostate  is  often  very  erec- 
tile and  is,  therefore,  singularly  capable  of  sudden  and  rapid  enlarge- 
ment from  congestion.     Its  capability  of  bleeding  is  enormous. 

Surgeons  who  have  removed  enlarged  median  lobes  are  often 
struck  with  the  disparity  in  size  between  the  lobe  felt  and  seen  in  situ 
through  the  suprapubic  oi)ening  and  the  same  lobe  shortly  after  it 
has  been  removed.  This  diminution  in  size  is  due  to  drainage.  The 
rapid  erection  of  the  prostate  causes  excessive  stretching  of  the  super- 
jacent mucous  membrane.  As  this  is  pegged  down  posteriorly  by 
the  unyielding  trigone  and  anteriorly  by  the  dense  orificial  attach- 
ment, its  veins  become  thinned  and  dilated;  finally  an  ulceration 
opens  into  their  channels.  It  used  to  be  the  custom  to  ascribe 
all  spontaneous  bleeding  from  enlarged  prostate  to  the  bursting  of 
varices  or  piles  of  the  bladder.  This  I  am  sure  is  a  mistake.  It  is 
true  that  certain  large  and  tortuous  veins  are  often  seen  with  the 
cystoscope  coursing  beneath  the  mucous  membrane  covering  the  in- 
travesical enlargement  of  the  prostate,  but  it  is  doubtful  if  definite 
congeries  of  tortuous  veins  meriting  the  name  of  varices  or  piles  often 
exist.  The  only  instances  I  have  been  able  to  find  in  European 
museums  are  in  Upsala,  Sweden  (Nos.  1229,  1388).  They  are  in- 
jected with  blue,  which  shows  their  character  well. 

Slight  spontaneous  hemorrhage  from  a  senile  enlarged  prostate 
which  does  not  obstruct  so  greatly  as  to  necessitate  catheterism  is 
not  uncommon.  Any  slight  mechanical  cause  may  suffice  to  repro- 
duce it  when  once  it  has  occurred.  Jolting  in  a  conveyance,  venereal 
indulgence,  or  a  slight  chill  may  produce  a  hemorrhage  without  reten- 
tion. The  bleeding  is  supposed  to  be  a  relief  to  the  prostate,  and  it 
may  be  so.  I  believe  in  some  instances  at  least  that  this  symptom 
is  a  local  expression  of  a  general  arterial  change,  for  some  patients 
who  have  suffered  thus  have  subsequently  died  of  apoplexy.  This 
observation,  however,  needs  the  correction  of  wider  experience. 

Prostatic  blood  may  escape  pure  in  the  intervals  between  urina- 
tion and  stain  the  shirt  or  bedclothes,  leading  the  medical  man  to 
believe  that  it  originated  in  the  anterior  urethra.  It  may  appear 
either  at  the  commencement  or  at  the  end  of  the  stream,  or  it  may 
pass  into  the  bladder  and  find  exit  with  the  contents  of  that  viscus. 
I  have  known  the  urine  black  for  days  from  this  source. 

Case. — Enlarged  Median  Lobe  of  the  Prostate — Sudden  Attacks  of 
Prof  use  Hemorrhage  imth  Masslqe  Clots.- — B.,  aged  70,  consulted  me 
in  August,  1894.  His  history  was  as  follows :  In  1886  he  was  seized 
with  retention  from  holding  his  urine  too  long.     A  silver  catheter 


576  FENWICK — DISEASES  OF  THE  URINE. 

was  used,  and  lie  bled  freely.  For  several  years  after  this  he  used 
a  soft  ruijber  catheter  once  daily.  Several  times  in  the  summers  of 
1887,  1888,  and  1889  he  had  profuse  hemorrhages  from  the  bladder. 
They  occurred  without  warning  and  were  accompanied  by  massive 
clots  which  had  to  be  removed  by  suction  through  a  large-eyed  silver 
catheter.  Toward  the  end  of  1892,  cystitis  appeared.  He  had  been 
repeatedly  examined  with  the  sound  but  no  stone  had  been  discovered. 
He  was,  however,  not  satisfied,  and  in  July,  1893,  ran  down  a  steep 
hill,  leaping  high  as  possible  all  the  while  to  ascertain  if  he  could 
feel  a  stone.  He  suffered  no  pain  from  this  unusual  exercise  at  the 
time,  but  intense  pain  came  on  next  day,  and  being  at  Wiirzburg 
he  was  sounded  by  Professor  Schonborn  and  a  large  calculus  was 
detected.  It  was  completely  removed  by  litholapaxy  in  three  houi's. 
It  was  then  supposed  that  the  cause  of  the  hemorrhage  had  been  dis- 
covered and  removed,  but  the  attacks  did  not  cease  and  the  profuse- 
ness  of  the  loss  was  not  at  all  diminished.  They  still  occurred  every 
few  months.  I  examined  with  the  cystoscope  and  found  a  small 
upraised  median  lobe ;  no  stone  existed,  the  bladder  was  capacious. 
There  was  not  the  slightest  difficulty  in  introducing  the  shortest 
cystoscope.  A  month  after  this  I  was  suddenly  summoned  to  see 
him.  The  bladder  was  distended  with  blood  clot,  and  it  was  with 
much  difficulty  that  I  passed  a  very  long  and  largely  curved  pros- 
tatic catheter  and  evacuated  by  suction  and  washing  some  eighteen 
ounces  of  black  clot.  The  i)rostate  was  swollen  to  a  remarkable  size 
and  the  median  lobe,  which  previously  had  been  inconsiderable,  was 
now  most  prominent.  The  patient  now  mentioned  that  he  had  suf- 
fered for  years  from  piles  which  bled  profusely,  the  blood  running 
down  his  trousers  on  to  the  floor,  and  that  when  they  bled  freely  the 
bladder  was  better.  He  recovered  completely  from  the  attack.  Add- 
ing to  this  other  and  similar  cases  in  which  I  have  seen  the  blood 
issue  from  the  surface  of  the  median  lobe,  I  have  but  little  doubt 
that  the  origin  of  the  hemorrhage  was  prostatic. 

Note  on  Cases   in  ivhich  Renal  Pain    Coexists  with    Vesical  Disease, 
and  Vesical  Pain  is  Experienced  in  Renal  Disease. 

Without  placing  too  much  stress  upon  cases  in  which  pain  is  ex- 
perienced at  some  point  of  the  urinary  tract  distant  from  the  actual  site 
of  the  hemorrhage,  it  is  wise  to  remind  the  reader  that  renal  pain  is 
not  infrequently  felt  in  ascending  tuberculosis,  although  the  bladder 
is  the  actual  source  of  the  bleeding.  Other  cases  are  also,  though 
rarely,  met  with  in  which  compression  of  the  lower  urethral  orifice 
by  vesical  growth  or  by  impacted  calculus  leads  to  backward  pres- 
sure on  the  pelvis  of  the  corresponding  kidney,  and  consequent  ten- 
sion pain  is  felt  in  the  loin.  Conversely,  though  still  more  rarely, 
cases  will  be  encountered  in  which  the  kidney  is  the  seat  of  a  stone 
which  is  exciting  hemorrhage,  but  the  pain  is  experienced  not  so 
much  in  the  kidney  as  in  the  bladder  and  urethra.  It  is  much  more 
common  to   meet  with  sympathetic  vesico-urethral  pain  in  pyuria 


TREATMENT  OF   HtEMATURIA.  577 

of  renal  origin,  and  notice  will  be  taken  of  this  subject  under  the 
heading  of  jjus  in  the  urine. 

Treatment  op  H^ematuria. 

Before  considering  the  treatment  for  the  various  forms  of  spon- 
taneous hsematuria,  it  would  be  as  well  to  consider  whether  there  is 
any  which  had  better  be  left  unchecked.  I  believe  that  in  hard 
carcinomata  of  the  bladder,  in  engorged  senile  enlargement  of  the 
prostate,  and  in  renal  Jisematuria  the  result  of  cardiac  disease,  the 
bleeding  is,  to  a  certain  extent,  beneficial.  In  hard  carcinoma  there 
is  often  a  great  increase  of  pain  when  the  bleeding  is  arrested  and  a 
sensible  diminution  of  the  suffering  when  it  has  become  re-estab- 
lished. The  treatment  of  these  cases  is  hopeless,  and  it  is  better  and 
kinder  policy  to  allow  the  patient's  life  to  ebb  away  rather  than  to 
prolong  his  misery  by  conserving  his  blood  caj)ital.  In  those  con- 
gested senile  prostates  which  bleed  periodically,  I  suspect  that  there 
is  a  tendency  to  atheromatous  degeneration  of  the  vessels,  and  the 
bleeding  acts  not  only  as  a  safety-valve,  but  serves  to  deplete  an  over- 
tense  tissue.  In  real  hemorrhage  from  obstructive  mitral  disease  or 
granular  kidney,  the  high  blood  pressure  is  often  greatly  relieved  by 
a  slight  intermittent  haematuria. 

In  these  three  diseases,  then,  I  would  suggest  that  the  practitioner 
do  not  hastily  check  a  hemorrhage  which  may  be  affording  his  patient 
relief. 

Although  the  successful  and  scientific  treatment  of  spontaneous 
hsematuria  depends,  of  course,  upon  ascertaining  and  removing,  if 
possible,  the  cause  of  the  hemorrhage,  yet  occasionally  the  practi- 
tioner is  not  able  to  do  more,  in  sudden  and  urgent  cases,  than  to 
combat  the  immediate  effects  of  the  loss  of  blood. 

The  first  and  most  essential  step  is  to  allay  the  patient's  fears  and 
to  restore  confidence.  To  many  the  appearance  of  blood  issuing 
from  so  unusual  a  channel  as  the  urethra  is  most  alarming.  From 
my  own  experience,  I  am  sure  that  in  the  large  majority  of  cases  a 
promise  may  be  made  that  the  hemorrhage,  if  it  is  the  first  or  among 
the  first  attacks,  will  subside  with  proper  precautions  in  two  or  three 
days.  When  the  hsematuria  has  once  become  established,  it  is  other- 
wise. 

Position. — Absolute  rest  in  bed  is  of  primary  importance;  many 
severe  hgematurias  can  be  readily  controlled  in  their  early  stages  by 
the  recumbent  position.  It  must  be  rigidly  enforced  in  proportion 
to  the  severity  of  the  attack.  High  elevation  of  the  pelvis  is  of  real 
value  in  certain  cases  of  vesico-prostatic  bleeding. 

ApplicQLtion  of  Gold. — The  external  application  of  cold  is  of  value, 
Vol.  I.— 37 


578  FENWICK — DISEASES    OF  THE  UEESTE. 

perhaps  more  to  quiet  the  apprehensions  of  the  patient  than  for  much 
good  it  will  do  in  the  hsematurias  of  the  lower  urinary  tract.  It  is 
certainly  of  great  value  in  ruptured  kidney,  for  here  it  not  only  assists 
in  checking  the  bleeding,  but  also  mitigates  the  traumatic  peritonitis* 
which  sometimes  ensues  even  when  the  peritoneum  has  been  untorn 
and  the  other  viscera  uninjured.  Cold  may  be  very  efficiently 
applied  by  means  of  ice-bags  over  the  loin  or  over  the  bladder ;  but 
a  cleaner  and  easier  method  is  by  Leiter's  pliable  coils,  which  may  be 
moulded  to  any  part,  and  through  which  a  continuous  current  of  cold 
water  can  be  conveyed.  I  place  a  certain  amount  of  reliance  upon 
ice  in  the  rectum  for  checking  hemorrhage  from  the  bladder  and  es- 
pecially from  the  prostate.  I  believe  it  causes  contraction  of  the 
muscle  planes  of  the  wall  of  the  bladder  as  well  as  those  of  the  blood- 
vessels. It  is  a  good  plan  to  throw  each  piece  of  ice  into  warm 
water  to  smooth  off  the  sharp  edges  of  the  fragment  before  pushing 
it  into  the  rectum. 

Drugs. — I  cannot  speak  very  highly  of  any  styptic  by  the  mouth. 
In  sharp  arterial  bleeding,  ergot  is  perhaps  the  most  reliable.  It  is 
given  in  doses  of  half  a  drachm  to  a  drachm  mixed  with  some  prepa- 
ration of  opium,  every  two,  three,  or  four  hours,  according  to  the 
severity  of  the  case.  If  the  hemorrhage  be  moderate  and  dark, 
fluid  extract  of  witch  hazel,  in  drachm  doses,  is  of  value.  Iron 
preparations,  such  as  the  iron  aluminate,  or  tannate  of  alumina  or 
acetate  of  lead  are  worth  a  trial  in  moderate  vesical  hemorrhage. 
In  the  profuse  vesical  hemorrhage  in  atonic  bladders,  ergot  and  nux 
vomica  combined  with  gallic  acid  is  perhaps  the  best  remedy  to  ad- 
minister. In  some  cases,  an  acidulated  drink,  or  the  acid  infusion 
of  roses,  answers  well. 

But  in  every  haematuria  some  sedative  ought  to  be  incorporated 
with  the  drug  selected.  I  usually  employ  opium  freely,  except  when 
there  is  reason  to  suspect  serious  renal  change  or  where  opium  is 
contra-indicated,  and  then  I  substitute  bromide  of  potassium,  hyos- 
cyamus  or  cannabis  indica.  Belladonna  is  best  avoided,  for  it  tends 
to  weaken  that  contractile  power  of  the  bladder  which  is  of  real  ther- 
apeutic value. 

Oil  of  turpentine  is  a  favorite  with  many.  It  has  the  disadvan- 
tage of  irritating  the  neck  of  the  bladder  in  some  patients ;  the  dose 
is  five  to  ten  minims  cautiously  increased,  given  either  in  capsules  or 
in  mistura  amygdalae, 

*  In  many  cases  of  sudden  and  profuse  loss  of  blood,  whether  from  the  kidney, 
bladder,  or  prostate,  the  shock  and  exhaustion  will  be  marked  by  distention  of  the 
gut,  consequent  tympanites,  and  general  but  not  severe  abdominal  pain.  It  is  a 
mistake  to  consider  these  as  signs  of  peritonitis. 


TEEATMEl^T  OF  H^MATUEIA.  579 

Far  below  these  in  value,  but  warmly  recommended  by  various 
writers  as  having  especial  power  to  arrest  liaematuria,  are  a  number 
of  drugs  such  as  matico,  cinnamon,  liquorice,  lemon  juice. 

Professor  Guyon  places  very  little  reliance  on  styj)tics  by  the 
mouth.     He  aims  at  improving  the  general  constitutional  tone. 

An  attempt  may  be  made,  suggested  by  Professor  Wright's  work 
upon  the  coagulation  of  the  blood,  to  increase  the  coagulability  of  the 
blood  by  administering  chloride  of  calcium.  I  believe,  however,  that 
care  must  be  exercised  with  this  and  other  strong  styptic  drugs  in 
profuse  hsematuria,  for  the  tendency  with  such  remedies  is  to  increase 
the  size  of  the  clots,  and  this  is  especially  the  case  with  chloride  of 
calcium.  In  many  of  the  diseases  giving  rise  to  hemorrhage  after 
the  age  of  fifty  there  is  perceptible  diminution  of  the  expulsive 
power  of  the  bladder,  and  clot  dysuria  and  retention  and  all  their 
accompanying  septic  evils  may  easily  be  produced. 

Diet.- — Solid  food  had  better  be  avoided  until  the  severity  of  the 
attack  has  abated.  The  diet  should  be  bland,  very  limited  in  quan- 
tity, and  taken  cold.  If  thirst  be  complained  of,  it  may  be  allayed 
by  sucking  ice.  As  the  patient  improves,  the  diet  may  be  cautiously 
increased.  Alcohol  should  be  avoided  at  first,  but  in  a  day  or  two 
port  wine  may  be  added,  for  it  will  be  found  a  valuable  astringent. 
In  fact,  in  the  earlier  part  of  the  century  port  wine  used  to  be  consid- 
ered as  indicated  in  all  forms  of  hsematuria.  As  the  clots  which 
have  sealed  the  bleeding  orifices  are  liable  to  become  dislodged  on 
the  slightest  straining,  all  vomiting  and  retching  must  be  checked. 
Nutrient  enemata  must  be  administered  if  the  patient  continue  to 
show  a  tendency  to  sickness. 

Bowels. — In  profuse  hsematuria  the  entire  intestinal  canal  had 
better  be  kept  quiet  for  a  few  days ;  purgatives  are  contra-indicated. 

I  have  seen  a  copious  prostatic  hemorrhage  supervene,  and  the 
case  terminate  fatally,  on  the  exhibition  of  a  purgative  three  days 
after  a  perineal  lithotomy.  On  the  other  hand,  if  the  abdomen  gets 
distended,  and  solid  faeces  collect,  they  had  better  be  removed  by 
means  of  a  rectal  enema  of  oil  or  soap  and  water. 

Morris"  states  "that  he  has  seen  sharp  hgematuria  from  an  in- 
jured kidney  brought  on  unexpectedly  more  than  a  fortnight  after 
the  infliction  of  the  wound,  and  when  the  patient  appeared  to  be  con- 
valescent, by  the  j^assage  of  hardened  fsecal  matter  along  the  colon, 
and  thus  across  the  surface  of  the  kidney." 

Cht  Retention. — The  practitioner  may  find  himself  suddenly  called 
to  a  case  in  which  the  bladder  is  full  of  clot  and  the  viscus  is  felt  like 
a  hard  mass  i^rojecting  above  the  pubes.  Under  such  circumstances, 
it  is  advisable  to  inquire  whether  the  bladder  has  proved  itself  able 


580  FENWICK — DISEASES   OF   THE  UEINE. 

to  evacuate  its  contents  before  tlie  onset  of  the  trouble,  and  if  it  has 
always  worked  well,  it  is  wise  to  wait  awhile  and  give  the  vesical 
muscle  time  to  do  its  own  work  and  rid  the  viscus  of  the  clots.  The 
pain  should  be  subdued  by  means  of  opium  and  warm  applications 
to  the  suprapubic  and  perineal  regions. 

If  clot  retention  and  vesical  colic  are  not  spontaneously  relieved 
within  a  few  hours,  and  the  patient  is  obviously  made  worse  by  wait- 
ing, then  the  practitioner  must  intervene.  A  large-eyed  soft  catheter, 
which  has  been  syringed  through  with  oil,  must  be  passed  very 
gently.  This  may  suffice — the  clots  and  accumulated  urine  coming 
away,  or  most  of  the  urine  maj-  be  evacuated  and  the  clots  which 
cannot  issue  may  be  allowed  to  come  away  at  a  subsequent  micturi- 
tion. This  manoeuvre  is  not  always  successful,  for  the  eye  of  the 
catheter  sometimes  becomes  blocked  with  clot,  and  the  retention  is 
thus  unrelieved. 

A  large-eyed  silver  catheter  had  then  better  be  passed  and  warm 
boracic  solution  syringed  in  whenever  the  channel  becomes  .choked. 
By  alternately  syringing  in  solution  and  sucking  out  clot  and  fluid 
the  bladder  will  probably  be  cleared.  When  this  is  accomplished  it 
is  wise  to  throw  into  the  bladder  eight  ounces  of  nitrate  of  silver  solu- 
tion (gr.  i.  ad  5  viij.),  which  slightly  coagulates  the  surface  epithelium 
and  prevents  septic  absorption. 

Teeatment  of  the  Yaeious  Causes  of  H^matueia. 

Carcinoma  of  the  Kidney. 

Medicinal. — Probably  tincture  of  chloride  of  iron  will  prove 
most  efficacious.  Ergot  or  chloride  of  calcium  may  be  exhibited  for 
some  time  on  the  expectation  of  increasing  the  coagulability  of  the 
blood.  The  disadvantage  of  these  styptics  is  the  difficulty  of  getting 
rid  of  the  clots  they  cause,  for  it  is  only  at  the  expense  of  much  renal 
suffering  that  they  will  be  forced  along  the  ureter.  On  no  account 
should  the  bladder  be  sounded  or  washed  out  if  a  decided  tumor  is 
discovered  in  the  loin.  It  may  not  be  harmful,  but  it  has  been  fol- 
lowed by  serious,  even  fatal  results. 

Operative. — The  statistics  of  nephrectomy  for  carcinoma  are  en- 
couraging enough  to  permit  us  to  hope  that,  with  an  earhj  diagnosis, 
we  may  achieve  a  success  in  removing  a  renal  carcinoma.  Schede, 
of  Hamburg,  records  a  series  of  ten  cases  of  nephrectomy  for  differ- 
ent diseases  without  a  death.  Previous  to  this  he  had  operated 
seven  times  with  six  recoveries,  thus  making  a  total  of  seventeen 
cases  with  one  death.  This,  as  the  cases  are  not  picked,  shows  how 
the  mortality  has  decreased  in  the  hands  of  a  highly  skilled  general 


TREATMENT  OF  THE  VARIOUS  CAUSES  OF  HEMATURIA.  581 

surgeon,  for  the  statistics  of  Gross  showed  a  mortality  of  44.6  per 
cent.,  of  Brodeur  44.4  per  cent.,  of  Czerny  44.4  per  cent.,  of  Morris 
30.4  per  cent.,  and  of  Tait  18  per  cent.  Of  the  ten  cases  last  recorded 
by  Schede  three  were  for  carcinoma.  No  case  is  at  present,  I  believe, 
published  in  which  the  renal  artery  has  been  tied  to  check  hemor- 
rhage and  new-growth,  though  there  is  no  reason  why  this  should 
not  be  attempted.  The  future  of  nephrectomy  in  renal  carcinoma 
depends  upon  a  diagnosis  being  made  and  acted  upon  very  early  in 
the  course  of  the  disease ;  for  the  general  feebleness  of  the  patient 
and  the  intimate  connections,  whether  inflammatory  or  neoplastic, 
which  the  kidney  acquires  with  surrounding  stractures,  render  the 
operation  very  hazardous  in  itself,  while  the  generalization  which 
rapidly  takes  place  makes  operative  interference  useless  if  it  is  not 
undertaken  soon  after  the  degeneration  has  commenced. 

I  regard  anaemia  as  an  important  contra-indication  to  operative 
interference. 

As  the  tumor  increases  in  size,  it  may  press  upon  the  vessels  and 
strangle  the  blood-supply,  or  the  renal  pelvis  and  ureter  may  become 
.filled  with  clot  which  will  render  that  canal  permanently  impervious. 
In  either  case,  the  hsematuria  ceases. 

Chronic  BrigJifs  Disease. 

The  hgematuria  of  granular  kidney  is,  I  believe,  best  treated  by 
absolute  rest  in  bed,  and  a  strict  diet  of  milk.  If  the  hemorrhage  is 
not  excessive,  and  the  patient  is  able  to  get  about,  Turkish  baths 
(without  massage  and  the  cold  douche)  may  be  taken  with  benefit  and 
the  bleeding  often  abruptly  ceases  in  consequence,  the  free  action  of 
the  skin  reducing  the  congestion  of  the  kidney.  But  if  the  hemor- 
rhage has  proved  obstinate  or  profuse,  it  is  better  that  the  patient 
should  keep  to  the  bed,  a  hot-air  bath  being  administered  by  means 
of  a  cradle  and  a  spirit-lamp. 

The  most  convenient  form  is  that  in  which  the  air  is  heated  in  a 
receiver  by  means  of  a  spirit-lamj),  and  is  conveyed  under  the  bed- 
clothes, which  are  supported  over  the  patient  by  means  of  an  iron 
cradle.  The  following  mixture  may  be  given  simultaneously  with 
benefit : 

1$  Tr.  digitalis 3  i. 

Tr.  hamamelidis §  ss. 

Ext.  glycyrrhiza3  liquidse 3  ij. 

Aqufje  destillatse q.  s.  ad  §  viij. 

M.  ft.  mist.    Sig.  Two  tablespoonfuls  three  times  a  day. 

All  stimulating  diuretics,  such  as  Juniper,  turpentine,  cantharides, 
copaiba,  santal,  or  cubebs,  sliould  be  avoided.     The  bowels  had  better 


582  FENWICK— DISEASES  OF  THE  URINE. 

be  acted  upon  very  gently,  preferably  by  means  of  rectal  enemata  of 
soap  and  water  or  glycerin. 

The  renal  lisematuria  in  sypliilitics  may  be  combated  by  ordinary 
antisypliilitic  treatment,  a  valuable  addition  to  the  mixture  being  the 
compound  decoction  of  sarsaparilla  and  the  extract  of  hamamelis 
virginica. 

The  hsematuria  occurring  in  cardiac  disease  and  in  the  acute  ne- 
phritis grafted  on  chronic  Bright' s  disease,  must  be  treated  on  the 
usual  principles  laid  down  for  these  diseases. 

Stone  in  the  Kidney. 

The  appropriate  treatment  for  haematuria  caused  by  calculous 
disease  of  the  kidney  must  be  varied  slightly  according  to  the  charac- 
ter of  the  urinary  deposit.  If  the  microscope  or  the  eye  detect  a 
uratic  condition  of  urine  without  pus,  then  moderate  rest,  a  spare  diet, 
avoidance  of  all  alcohol,  and  the  free  use  of  alkaline  waters,  such  as 
Contrexeville,  KronenqueUe,or  Wildungen,  will  usually  suffice  to  check 
any  tendency  to  heematuria.  The  bowels  had  better  be  regulated  by 
a  dose  of  phosphate  of  sodium  (two  teaspoonfuls)  well  diluted  with 
water  each  morning.  If  the  alkaline  waters  cannot  be  obtained,  a 
teaspoonful  of  effervescing  citrate  of  potash  in  half  a  tumblerful  of 
water  may  be  taken,  or  a  very  useful  sherbet  can  be  made  thus : 

I^  Potass,  citratis §  i. 

Lithii  citratis 3  ij. 

Sodii  biboratis 3  vss. 

Sacchari  albi q.  s.  ad  3  iv. 

Ess.  limonis irixvi. 

M.  ft.  pulvis. 

Keep  in  a  glass-stoppered  bottle.  A  teaspoonful  to  be  taken  in 
a  tumblerful  of  water  twice  a  day. 

Boracite  of  magnesia  is  advocated  by  Dr.  Kochler  of  Posen 
{Berliner  Minische  Wochemchrift,  Nov.  3d,  1879)  for  cases  of  uric-acid 
calculi  and  gravel.  It  is  prepared  by  dissolving  a  natural  borate  of 
magnesia,  which  is  found  at  Stassfurt,  in  citric  acid.  It  may  be 
taken  twice  or  thrice  daily  in  teaspoonful  doses  dissolved  in  a  tum- 
blerful of  warm  water. 

Hemorrhage  in  oxaluria  and  oxalate  of  lime  calculus  is  perhaps 
more  difficult  to  arrest.  No  brusque  movements  should  be  allowed ; 
the  diet  must  be  stricter,  and  free  from  sugar  in  any  form ;  all  un- 
cooked fruits  ought  to  be  avoided.  Usually  the  acids  in  some  bitter 
infusion  succeed  best.     The  following  is  valuable : 

'Ey  Acidi  nitro-hydrochlor.   dil '"1x1. 

Infusi  rosse  acidi q.  s.  ad  I  viij. 

M.  ft.  mist.     Sig.  Two  tablespoonfuls  between  meals  thrice  a  day. 


TREATMENT  OF  THE  VARIOUS  CAUSES  OF  HJEMATUKIA.  583 

Hemorrhage,  when  due  to  j)hosphatic  calculi,  the  urine  being 
usually  alkaline,  often  abates  on  the  exhibition  of  the  citro-borate  of 
magnesia,  or  after  a  combination  of  boric  acid  and  benzoate  of  soda 
with  infusion  of  chiretta  or  serpentary.  If  there  is  jms  also  present 
in  the  urine  the  balsamic  drugs  are  of  value  when  taken  in  capsule  at 
night  after  sujjper:  turpentine,  five  drops;  copaiba  oil,  ten  drops; 
santal  oil,  ten  drops  cautiously  increased.  The  diet  must  be  liberal 
and  varied,  and  some  form  of  stimulant  should  be  added.  Skilled 
nephrolithotomy,  if  no  suppuration  has  taken  place,  is  free  from  risk. 

The  Hcematuria  of  Benign  or  Malignant  Ch^owths. 

No  drug  can  be  relied  upon  to  check  a  well-established  hemor- 
rhage from  vesical  growth,  whether  benign  or  malignant.  Any  or  no 
drug  will  suffice  in  the  very  early  stages,  gallic  acid  and  opium  being 
perhaps  as  good  as  any.  Everj^  haemostatic  may  be  tried  in  turn, 
and  one  may  be  chanced  ui)on  which  suits  the  patient  and  holds  the 
loss  in  check.  Should  the  bleeding  become  alarming,  and  operation 
be  refused,  much  good  can  be  done  by  the  passage  of  a  soft  Jacques 
catheter  in  order  to  partially  empty  the  bladder — the  final  contraction 
of  the  viscus  and  the  consequent  traumatic  escape  of  blood  from  the 
growth  being  prevented  by  leaving  an  ounce  or  two  of  urine  behind. 
If  this  fails,  vesical  irrigation  should  be  tried.'  I  know  of  few  better 
injections  than  hot  hazeline,  or  hot  hazeline  and  water  (equal  parts) . 
Prout  recommends  that  twenty  to  forty  grains  of  alum,  dissolved  in 
a  pint  of  w^ater,  should  be  injected  into  the  bladder.  He  says :  This 
remedy  seldom  fails  to  check  the  bleeding  even  when  the  cause  is 
malignant  disease.  I  have  nevfer  known  any  unpleasant  consequences 
follow  the  use  of  this  expedient,  and  I  have  seen  it  immediately  arrest 
the  most  formidable  hemorrhage  when  all  other  means  had  failed, 
and  when  the  bladder  had  repeatedly  become  again  distended  with 
blood  almost  immediately  after  its  removal." 

Sir  Henry  Thompson  has  great  confidence  in  astringent  injections 
thrown  into  the  bladder  with  extreme  gentleness,  and  through  a  small 
catheter.  The  two  which  he  uses  for  cases  in  which  operation  is  not 
as  yet  decided  on,  and  especially  for  those  in  which  the  tumor  has 
been  only  partially  removed,  are  perchloride  of  iron  and  nitrate  of  sil- 
ver. "  The  strength  employed  is  from  twenty  to  sixty  minims  of  the 
tincture  of  the  perchloride  of  iron  in  four  ounces  of  cold  water,  to  be 
used  daily  once  or  twice  according  to  circumstances ;  of  the  nitrate  of 
silver,  from  gr.  i.  to  gr.  vi.  in  four  ounces  of  water,  the  stronger  so- 
lutions being  rarely  tolerated  or  necessary." 

I  have,  personally,  the  greatest  objection  to  using  styptic  injections 
and  very  rarely  employ  them.     They  are  often  provocative  of  cystitis. 


584  FENWICK — DISEASES  OF  THE  UEINE. 

Now  cystitis  militates  against  the  successful  removal  and  rapid  cure 
of  a  benign  growth,  while  it  is  the  turning-point  in  the  life  of  a 
malignant  vesical  tumor.  After  cystitis  has  been  induced,  or  upon 
its  appearance  in  vesical  carcinoma,  there  is  an  immediate  increase  in 
the  pabulum  of  blood  which  is  conveyed  to  the  malignant  mass  and 
utilized  in  its  construction.  All  the  misery  and  pain  caused  by  irrita- 
tive cystitis  and  the  necrosis  of  the  surface  of  the  tumor  are,  therefore, 
summoned  weeks  or  months  before  they  otherwise  would  appear  if 
the  disease  were  permitted  to  take  its  course. 

Operative  Interference. — The  suprapubic  removal  of  vesical  growth 
of  the  benign  type  ought  to  be  free  from  risk  if  it  be  undertaken 
before  degenerative  changes  in  the  kidney  have  ensued.  A  fatality 
in  straightforward  cases  is  a  surgical  discredit.  Any  interference 
with  the  surface  of  a  benign  growth  checks  the  bleeding  for  months. 
This  is  not  so  in  all  carcinomata ;  nothing  short  of  free  surface  re- 
moval stops  the  hemorrhage. 

Primary  Tuberculosis  of  the  Kidney  and  Bladder. 

This  hemorrhage  is  rarely  of  much  moment,  and  the  treatment  of 
it  is  the  same  as  that  which  is  usually  directed  against  inflammation 
or  ulceration  of  the  genito-urinary  mucous  membrane.  Of  drugs  the 
oil  of  sandalwood  is  the  best.  It  is  taken  in  capsules  in  doses  of 
five  minims,  cautiously  increased  to  fifteen,  thrice  a  day  after  food. 

If  the  renal  pain  is  aggravated  by  its  use,  the  balsamic  oil  had 
better  be  at  once  replaced  by  a  less  stimulating  drug,  such  as  citrate 
of  potash,  boric  acid,  or  benzoate  of  ammonia.  In  all  cases  prepara- 
tions of  opium  are  of  value,  and  later  on  the  orthodox  maltine  and 
cod-liver  oil.  The  patient  should  be  sent  for  change  of  air,  and  have 
a  liberal  and  fatty  diet.  Change  to  the  sea-side  for  town-dwellers,  and 
to  an  inland  dry  climate  for  those  living  on  the  seaboard,  is  usually 
sufficient  to  hold  the  hemorrhage  in  abeyance. 

In  the  earlier  stages  of  tubercular  ulceration  of  the  bladder  the 
bleeding  may  be  checked  by  the  administration  of  santal  oil  or  malt- 
ine, and  in  some  cases  by  the  insertion  twice  a  day  of  a  rectal  sup- 
pository of  morphine.  As  a  last  resource  a  single  but  thorough  wash- 
ing out  of  the  bladder  with  boiled  filtered  water  will  often  be  quite 
sufiicient  to  check  even  smart  hemorrhage  due  to  vesical  ulceration  in 
the  earlier  stages.  As  the  disease  progresses,  tincture  of  witch  hazel, 
a  drachm  to  the  ounce  of  boiled  water,  may  be  iised,  or  five  grains 
of  iodoform  suspended  in  an  ounce  of  mucilage  may  be  thrown  into 
the  bladder  and  left  in;  or  lactic  acid  1  per  cent,  may  be  injected  to 
overcome  the  tendency'-  to  phosphatic  deposits  which  induce  and  keep 
up  haematuria.     There  is,  however,  great  need  for  extra  circumspec- 


TREATMENT  OF  THE   VARIOUS  CAUSES  OP  HiEMATURIA.  585 

tion  as  regards  cleanliness  and  gentleness  in  dealing  with  tuberculosis 
topically.  In  the  later  stages  when  the  prostate  has  become  involved, 
it  is  better  not  to  wash  out  the  bladder  or  to  pass  any  instrument 
through  the  deep  urethra  at  all.  I  have  known  bleeding  from  deep 
ulceration  resist  all  remedies  and  yield  only  to  drainage,  but  this 
step  should  be  a  last  resource. 

Stricture  of  the  Urethra. 

The  hemorrhage  due  to  stricture  usually  subsides  on  gradual  but 
free  dilatation  and  the  use  of  nux  vomica  and  alkaline  mixtures. 

Stone  in  the  Bladder. 

As  this  usually  subsides  in  proportion  as  the  pus  in  the  urine 
increases,  it  will  only  be  in  the  earlier  stages  that  advice  is  sought 
to  check  a  hemorrhage.  Any  hgemostatic  combined  with  opium  will 
stop  the  bleeding,  but  nothing  but  the  removal  of  the  stone  will  of 
course  cure  it.  If  prostatic  engorgement  coexists  and  the  sounding 
has  been  severe,  the  hemorrhage  may  persist  for  a  long  time.  In  the 
latter  case  gallic  acid  and  opium  had  better  be  administered  in  addi- 
tion to  the  routine  remedies  for  allaying  cystitis.  If  the  patient  is 
forced  to  move  about,  and  is  in  catheter  life,  the  injection  into  the 
bladder,  thrice  a  day,  of  an  ounce  of  warm  oil,  with  which  a  tea- 
spoonful  of  tincture  of  witch  hazel  has  been  thoroughly  mixed,  will 
often  be  sufficient  to  allay  irritation  and  check  hemorrhage. 

Prostatic  Congestions. 

The  slight  bleeding  in  prostatic  congestion  due  to  gonorrhoea  or 
to  sexual  excesses  is  probably  beneficial.  If,  however,  it  shows 
any  tendency  to  profuseness,  ice  in  the  rectum  is  indicated.  If  this 
does  not  arrest  the  loss,  any  of  the  balsamic  remedies  are  of  service, 
and  in  addition  gallic  acid  and  opium  should  be  administered. 
Gross  asserts  that  frightful,  even  fatal  hemorrhage  has  been  occa- 
sioned by  masturbation.  I  have  never  met  with  such  a  case,  but  I 
have  encountered  violent  hemorrhage  due  to  reckless  instrumentation 
of  a  prostate  swollen  and  inflamed  by  masturbation,  and  I  was  forced 
to  do  a  perineal  section  and  remove  the  clots  by  means  of  a  powerful 
syringe  before  I  could  clear  the  bladder.  So  untoward  an  event  can 
but  seldom  occur. 

Senile  Prostatic  Enlargemeyit. 

a.  Without  Vesical  Atony. — The  hemorrhage  in  many  of  these  cases 
is  beneficial,  free  from  danger,  and  yields  to  recumbency,  acidulated 
drinks,  and  gallic  acid  and  opium.     Ergot  has  occasionally  appeared 


586  I^NWICK — DISEASES  OF  THE  URmE. 

in  my  hands  to  increase  the  bleeding.  It  is  surprising  for  what  length 
of  time  clots  will  remain  in  healthy  acid  urine,  without  undergoing 
bacterial  decomposition.  They  slowly  disintegrate  and  are  passed  like 
tea-leaves  or  slips  of  light  tan.  For  this  reason  I  should  advise  that 
the  catheter  be  not  hastily  used  unless  the  bladder  is  atonic  and  unable 
to  cojDe  with  the  obstruction  caused  by  the  clots.  If,  however,  the 
urine  is  alkaline  and  ammoniacal,  cystitis  from  the  decomposition  of 
the  clot  will  rapidly  develop,  and  the  catheter  should  be  used  at  once 
to  anticipate  this,  the  bladder  being  thoroughly  washed  out. 

b.  With  Vesical  Atony. — The  hemorrhage  which  ensues  in  cases 
of  enlarged  prostate  in  atonic  bladders  is  often  difficult  to  treat. 
In  a  clinical  lecture  upon  hfematuria  at  St.  Peter's  Hospital,  my 
colleague,  Mr.  Harrison,  made  the  following  very  apt  and  valuable 
remarks,  aproijos  of  this  subject:  "There  is,  however,  a  condition  of 
the  senile  bladder  which  adds  considerabh^  to  the  trouble  connected 
with  bleeding.  I  refer  to  those  instances  where  it  occurs  with  a  large 
prostate,  and  an  atonic  or  almost  completely  atonic  bladder.  The 
great  safeguard  against  prostatic  hemorrhage  is  the  power  of  the 
bladder  to  exercise  pressure.  In  two  instances  not  only  had  I  to 
empty  the  bladder  of  blood,  but  to  keep  it  empty  by  pressure  upon 
it  and  the  retention  of  a  catheter  until  the  tendency  to  bleed  had 
ceased,  just  as  is  done  with  the  flaccid  uterus.  In  both  the  instances 
I  refer  to  this  was  successfully  accomplished,  and  the  patients  recov- 
ered, though  the  loss  of  blood  was  considerable.  It  is  not  the  least 
use  depending  upon  hemostatics  in  cases  such  as  these.  The  me- 
chanical reason  why  the  bleeding  will  not  cease  must  be  recognized 
and  acted  upon,  or  the  patients  will  flood  to  death,  with  their  bladders 
distended  with  blood  up  to  the  umbilicus." 

PYURIA. 

When  pus  is  passed  in  urination,  the  symptom  is  known  as 
Pyuria.  Our  knowledge  of  the  causes  of  this  morbid  change  is, 
however,  inexact,  for  it  is  sometimes  impossible  on  clinical  grounds 
to  judge  of  the  exact  source  of  the  pus,  while  with  the  cystoscope  it 
is  equally  difficult  to  make  sure  that  the  changes  which  are  seen  in 
the  mucous  membrane  of  the  bladder  indicate  the  only  area  from 
which  the  pus  is  emanating. 

Micro-Chemical  Characters  and  Tests  for  Pus. 

Pus  is  partlj^  composed  of  a  liquid  portion — the  liquor  puris — and 
partly  of  solid  cellular  particles— the  jjus  corpuscles.  The  liquor 
puris,  which  is  merely  liquor  sanguinis,  contains  a  variable  amount 


SOUECH  OF-PUS  m  TfiE  tRlNE.  587 

of  albuminous  constituents,  and  urine,  therefore,  which  contains  pus 
must  also  show  evidence  of  albumin  in  proportion  to  the  amount  of  pus 
present.  It  is  often  a  matter  of  considerable  difficulty  to  decide  as 
to  whether  the  amount  of  albumin  present  can  be  accounted  for  by 
the  pus,  or  whether  there  is  albumin  from  renal  degeneration  super- 
added. This,  however,  will  be  treated  of  under  the  head  of  acciden- 
tal albuminuria. 

The  pus  cell  microscopically  is  spherical  and  larger  than  a  blood 
corpuscle,  having  a  diameter  of  -^V  to  y-J-o-  millimeter,  and  is  heavier. 
Sometimes  it  is  irregular  in  shape  from  the  processes  it  sends  out.* 
Spherical  forms  mark  transitory  pyurias.  If  water  is  added  the 
cell  becomes  larger  as  well  as  clearer.  If  acetic  acid  is  added  the 
nucleus  will  be  seen  divided  into  three  or  more  nucleoli.  Similar 
changes  occur  in  the  urine.  If  the  secretion  be  acid  and  concentrated 
the  pus  cells  appear  small  and  granular,  if  the  urine  be  alkaline  or  of 
low  specific  gravity  the  pus  cells  are  large  and  swollen.  The  chemi- 
cal test  for  pus  in  the  urine  is  identical  with  one  of  its  chief  clinical 
characteristics.  If  liquor  potassse  or  liquor  ammonise  be.  added  to 
puriform  urine,  the  pus  becomes  converted  into  a  viscid  mass  (Donne's 
test) .  Puriform  urine  is  always  more  or  less  murky,  f  In  acid  or 
neutral  urine  the  pus  sinks  to  the  bottom  of  the  glass  and  forms  a 
more  or  less  thick  creamy  layer.  But  in  urine  alkaline  from  ammoni- 
acal  decomposition,  the  pus  is  transformed  into  a  clear  viscid,  glairy, 
tenacious  mass.  To  distinguish  between  pus  and  mucus  I  w^hen  both 
are  present  is  often  difficult :  it  is  advised  to  add  mercuric  chloride, 
which  precipitates  the  jjyin  but  not  the  mucin ;  this  is  filtered  off 
and  the  filtrate  containing  the  mucin  is  precipitated  by  acetic  acid. 

The  Source  of  Pus  in  the  Urine. 

Pus  may  emanate  from  any  part  of  the  urinary  tract  or  may  break 
into  it  at  any  point  and  be  discharged  along  with  the  urine.  The 
source  is  decided  ujjon  after  careful  examination  of  {A.)  the  urine, 
and  (B.)  the  patient. 

*  Vogel  calls  attention  to  this  difference  in  pus  cells  in  the  urine,  and  declares 
that  their  occurrence  in  the  irregular  form  affords  a  much  less  favorable  prognosis 
than  when  they  are  globular  (Ultzraann) . 

t  Bacteria  may  render  the  urine  murky  and  the  cloudiness  may  be  considered  as 
entirely  due  to  pus.  Pus  must  of  course  be  present,  but  it  may  be  in  small  quanti- 
ties, the  acuteness  of  the  inflammation  associated  with  the  bacteria  having  subsided. 
It  will  be  noticed  that  bacterial  clouds  are  very  long  in  falling  to  the  bottom  of  the 
glass — but  the  microscope  settles  the  point. 

X  Tyson  says  :  "  The  pus  corpuscle  is  a  cell  too  rapi<^lly  produced  to  develop  into 
normal  tissue,  wliile  the  mucus  corpuscle  is  only  accidentally  arrested  in  its  develop- 
ment. "     ("Guide  to  the  Practical  Examination  of  Urine,  "  4th  ed.,  p.  152). 


588  KENWICK— DISEASES  OE  THE  URINE. 

A.  Examination  of  the  Urine. 

1.  A  large,  thick,  creamy  deposit  of  pus  in  acid  urine  is  generally- 
due  to  disease  of  the  upper  urinary  passages,  e.g.,  pyelitis,  chronic 
pyelonephritis.  It  separates  much  more  quickly  than  does  pus  from 
the  bladder,  and  the  sample  maj^  remain  acid  and  free  from  micro- 
organisms for  days.     The  secretion  of  urine  is  usually  abundant. 

2.  The  constant  presence  of  viscid,  glairy  muco-pus  marks  a  vesical 
source.  This  rule  is  absolutely  correct  if  taken  in  conjunction  with 
bladder  symptoms.  Once  or  twice  I  have  been  deceived  by  patients 
bringing  me  a  bottle  of  urine,  with  a  large  clump  of  phosphatic 
muco-pus  slightly  coated  with  blood,  and  with  the  assurance  that  this 
clump  was  never  seen  in  the  day  but  was  only  passed  on  rising. 
Cystoscopically  one  or  other  ureteral  orifice  was  seen  to  be  inflamed, 
swollen,  and  pouting ;  the  surrounding  mucous  membrane  was  papil- 
lated,  as  if  fretted  by  irritating  discharges.  These  cases  puzzled 
me,  for  clear  urine  jetted  out  of  the  ureters  and  I  considered  the  kid- 
neys were  healthy.  One  jjatient  was,  however,  seized  with  a  sudden 
attack  of  severe  renal  pain,  a  symptom  he  had  not  suffered  from  for 
many  years.  He  was  admitted  into  another  hospital  and  nephrolithot- 
omy was  performed,  several  large  calculi  being  removed.  I  have 
since  realized  that  these  cystoscopic  appearances  indicate  irritation 
of  the  renal  pelvis,  and  I  account  for  the  morning  appearance  of  a 
clump  of  muco-pus  by  the  fact  that  residual  urine  acts  in  the  renal 
pelvis  during  the  hours  of  recumbency  exactly  like  residual  urine  in 
the  inflamed  bladder  and  undergoes  ammoniacal  changes. 

3.  Intermittent  Discharges  of  Pas  in  the  Urine. — When  large  amounts 
of  pus  appear  intermittently'  in  the  urine,  it  is  nearly  always  derived 
from  the  pelvis  of  the  kiduej^  the  ureter  of  which  has  become  tempo- 
rarily obstructed  by  a  plug  of  muco-pus,  or  by  slight  twisting  of  the 
canal.  It  may,  however,  in  rarer  cases  emanate  from  some  extra- 
urinary  source,  the  channel  of  communication  with  the  tract  be- 
coming periodically  closed.  The  symptoms  of  fever  which  accom- 
pany the  non-evacuation  of  the  pus,  but  which  subside  on  its  release, 
are  additional  evidences  of  the  pent  up  condition ;  while  the  pain  in- 
duced by  the  tension  is  generally  a  guide  to  the  anatomical  source  of 
the  discharge. 

4.  Threads  or  Flakes  of  Pus. — If  flakes  or  threads  of  pus  are  passed 
in  the  urine,  their  source  is  usually  urethral.  In  the  large  majority 
of  cases  this  is  quite  reliable.  The  threads  or  pus  fibres  are  formed 
by  the  issuing  stream  of  urine  sweeping  out  casts  of  ducts  leading 
into  the  urethra,  or  rolling  up  flakes  of  pus  and  sodden  epithelium 
which  cover  granular  patches  and  post-strictural  congestions.     Those 


SOURCE   OP  'PUS  IN  THE   URINE.  589 

threads  which  are  thin  and  long  usually  come  from  the  anterior  ure- 
thra, while  those  which  are  broad  and  thick  emanate  from  behind 
the  compressor  urfethrse  muscle. 

It  is,  however,  worthy  of  remark  that  pus  flakes  come  from  other 
parts  of  the  tract.  I  have  known  them  in  inflammation  of  the  renal 
pelvis,  and  in  renal  stone,  while  in  tuberculosis  of  the  bladder  and 
prostate  flakes  and  scrajjs  are  of  frequent  occurrence.  I  have  seen 
long  flattened  threads  made  by  thick  pus  being  forced  into  the  blad- 
der from  a  peri-vesical  abscess.  It  is  wise,  therefore,  before  deciding 
that  the  source  of  the  threads  is  urethral,  to  try  the  three-glass  test. 

The  Three- Glass  Test. — The  good  old-fashioned  test  of  making 
the  patient  urinate  into  two  glasses  is  of  value.  Into  the  first  are  car- 
ried the  sweepings  of  the  urethra  and  into  the  second  is  passed  the 
rest  of  the  secretion.  This  has  been  modified,  and  with  advantage,  by 
washing  out  the  anterior  urethra  with  boracic  solution  or  with  a  yV 
per  cent,  salicylic  acid  solution  (Key es) .  If  pus  is  found  in  the  first 
glass  or  in  the  washings,  and  the  second  glass  sample  is  normal,  the 
origin  of  the  pus  is  obviously  in  front  of  the  compressor  urethrse, 
and  the  bladder  is  free.  At  the  present  date  this  test  has  been  still 
further  extended  by  Finger,  Sehlen,  and  others,  so  as  to  embrace 
morbid  additions  from  the  prostate  and  seminal  vesicles.  After  the 
patient  has  cleared  the  urethra  by  urinating  an  ounce  or  two  into  a 
glass,  the  well-greased  forefinger  is  passed  into  the  rectum  and  the 
prostate  is  massaged  lightly  downward.  By  this  means  its  contents' 
,are  pressed  into  the  i)rostatio  canal  and  are  swept  into  another  glass 
by  another  jet  of  urine.  Lastly  the  remainder  of  the  urine  is  passed 
into  a  third  glass.  If  any  doubt  now  remains  as  to  whether  the  kid- 
ney or  the  bladder  is  furnishing  the  pus,  the  recommendation  of  Sir 
Henry  Thompson  is  to  be  followed :  A  soft  flexible  catheter  of  medium 
iiize  is  passed  into  the  bladder,  the  patient  standing,  all  the  urine  is 
drawn  off,  and  the  viscus  is  washed  out  by  repeated  small  injections  of 
warm  water.  The  urine  is  then  permitted  to  pass  along  the  catheter, 
as  it  will  do,  guttatim,  into  a  test-tube  or  other  small  glass  vessel  for 
purposes  of  examination.  "  The  bladder, "  says  Sir  Henry  Thompson, 
"  ceases  for  a  time  to  be  a  reservoir,  it  does  not  expand  but  is  con- 
tracted round  the  catheter,  and  the  urine  percolates  from  the  ureters 
direct.  The  ureters  are  virtually  lengthened  as  far  as  the  glass. 
Thus  is  obtained  a  specimen  which  for  appreciating  albumin,  for  de- 
termining reaction,  and  for  freedom  from  vesical  pus  and  even  blood, 
and  from  cell  growths  of  vesical  origin,  is  of  considerable  value,  and 
has  sometimes  furnished  me  with  the  only  data  previously  wanting 
to  accomx)lish  an  exact  diagnosis." 

5.   The  Amount  of  Alhumin  Present  in  Puriform  Urine. — The  urine 


590  FENWICK — DISEASES   OF  THE  TJEINE. 

of  pyelitis  always  contains  albumin  in  excess  of  that  due  to  tlie  pus 
present  in  the  secretion,  the  addition  marking  the  implication  of  the 
renal  structure.  When  one-half  to  one  per  cent,  by  weight  of  albumin 
exists  in  a  filtered  acid  specimen  of  puriform  urine,  without  blood, 
involvement  of  the  pelvis  of  the  kidney  in  the  inflammatory  process 
may  be  suspected.  In  decomposed  urine  containing  pus,  little  can 
be  inferred  from  the  albumin  tests   (E.  Fuller) . 

6.  The  3Iicroscopij  of  Purulent  Urine. — Much  stress  is  laid  upon 
this  by  many  authorities.  It  is  asserted  by  Ultzmann  that  short, 
thick  cylinders  formed  by  the  aggregation  of  pus  cells  come  from  the 
papillary  ducts  and  are  of  great  diagnostic  importance.  He  mentions 
also  that  renal  epithelial  scales  baked  as  it  were  into  pus  casts,  and 
isolated  epithelial  cells  coming  from  the  main  ducts  of  the  urinary 
tubules,  are  recognizable.  This  is  in  accordance  with  the  teaching  of 
continental  authorities.  The  accurate  recognition  needs,  I  am  sure, 
long  practice.  In  calculous  pyelitis  blood  corpuscles  are  often  pres- 
ent and  the  variety  of  crystals  Avhich  corresponds  to  the  stone  in  pro- 
cess of  formation.  In  tubercular  cases  the  debris  may  show  the  ba- 
cillus on  double  staining,  but  this  can  only  be  discovered  after  much 
examination  and  in  fresh  acid  urine.  When  during  a  chronic  pyelitis 
there  is  an  exacerbation  of  fever,  short  and  thick  granular  casts  are 
found  during  the  first  few  days  coming  from  the  larger  urinary  tu- 
bules. Klebs  directs  attention  to  large  clumps  of  bacteria  and  cocci, 
and  states  that  these  emanate  from  the  straight  tubes,  and  describes 
them  as  characteristic  of  "pyelonephritis  parasitica." 

7.  Experimental  Inoculation  and  Culture. — A  rabbit  should  always 
be  aseptically  injected  with  the  freshly  passed  urine  in  doubtful 
tubercular  cases,  and  culture  experiments  also  attempted. 

B.     Examinatwn  of  the  Patient. 

A  careful  examination  of  the  patient  should  be  undertaken  for 
evidences  of  disease  in  the  region  in  which  pain  is  complained  of. 
The  kidney  is  palpated  for  the  detection  of  tenderness  on  pressure,  of 
enlargement,  or  of  excessive  mobility ;  calculus,  pyelonephritis,  tuber- 
culosis, and  i^yonephrosis  being  the  main  causes  of  an  excessive 
amount  of  pus  in  the  urine.  The  bladder  should  be  examined  biman- 
ually,  both  when  empty  and  when  full.  Inflamed  bladders  are  al- 
ways tender,  and  if  ulcerated  are  acutely  sensitive.  Carcinomatous 
or  tubercular  deposits  are  nearly  always  recognizable,  and  calculi 
when  large  oan  be  felt  through  the  base. 

The  prostate,  vesiculse  seminales,  vasa  deferentia,  and  epididy- 
mis, are  examined  for  tenderness,  enlargement,  or  deposit  of  tubercle. 
The  projection  of  stones  in  the  prostate  is  detected  by  the  hardness 


SOUECE  OF., PUB  IN  THE  UBINE.  591 

and  grating,  for  they  usually  are  multiple.  The  bougie  will  eliminate 
stricture,  and  the  sound  will  serve  to  detect  prostatic  or  vesical  stone. 
Both  instruments  should  be  passed  with  the  same  precaution  as  those 
observed  in  hsematuria,  but  the  objection  to  using  them  is  less  in 
pyuria  than  when  blood  only  is  present.  The  cystoscope  will  dem- 
onstrate a  stream  of  j^us  issuing  in  a  dull  muddy  current  from  either 
ureter,  and  will  establish  the  presence  or  absence  of  vesical  causes  for 
pyuria.  The  spine  and  ribs  are  to  be  thoroughly  searched  for  tuber- 
cular lesions,  which  may  be  discharging  their  pus  into  the  upi)er 
urinary  tract.  The  uterus  and  its  surroundings  are  examined  in  the 
knee-and-elbow  position,  in  order  to  ascertain  if  any  inflammatory 
adhesions  exist  between  these  organs  and  the  bladder;  while  in  hip 
disease  the  inner  side  of  the  true  pelvis  is  thoroughly  swept  by  the 
finger  in  the  rectum,  to  make  sure  that  no  abscess  from  the  obturator 
cavity  is  apjjroaching  or  discharging  into  the  bladder. 

The  Significance  of  Pus  in  the  Urine. 

The  mucous  membrane  of  the  urinary  tract  seems  specially  prone 
to  become  irritated  in  middle-aged  and  elderly  people.  "  Exposure 
to  cold, "  says  Half e,  "  the  x>assage  of  urine  loaded  with  urates,  oxa- 
lates, or  phosphates  will  cause  the  presence  of  jpus  cells  in  the  urine. 
Even  the  use  of  highly  seasoned  dishes  will  often  produce  a  catarrh 
of  the  mucous  membrane,  in  feeble  and  delicate  persons,  sufficient  to 
lead  to  the  formation  of  pus  corpuscles."  The  transient  appearance 
of  slight  amounts  of  pus  in  the  urine  need  not,  therefore,  cause  alarm 
nor  arouse  suspicion  that  the  integrity  of  the  kidneys  or  urinary 
channels  is  being  threatened;  but  the  persistent  admixture  of  pus 
with  the  urine  in  visible  quantities  demands  close  investigation  and 
often  creates  anxiety  lest  serious  organic  changes  are  in  progress. 

Diagnostic  Significance  of  the  Symptoms  Accompanying  Pyuria. 

In  mild  simple  or  gouty  j)yelitis  or  cystitis,  especially  when 
this  occurs  in  the  female,  there  may  be  no  symptoms  present  to 
indicate  the  source  of  the  pus.  This  is  exceptional,  for  pyuria  is 
usually  accompanied  by  symptoms  of  functional  distress  in  the  organ 
which  is  inflamed,  and  the  patient  is  often  able  to  localize  the  site  of 
the  trouble  almost  as  surely  as  the  medical  man.  Cases  will,  how- 
ever; be  met  with  in  which  the  diagnosis  is  by  no  means  easy  on  ac- 
count of  the  conflicting  nature  of  reflex  symptoms,  for  one  inflamed 
portion  of  the  urinary  tract  may  excite  another  reflexly  or  by  "  sym- 
pathy," or  acrid  pus  flowing  from  an  upper  source  may  directly  irri- 
tate, in  its  transit,  a  lower  section  of  the  channel.  Complex  and  mis- 
leading symi>toms  are  thus  evoked  and  attention  is  drawn  to  an  organ 


592  FENWICZ — DISEASES  OF  THE  UKINE. 

wMcli  is  not  seriously  at  fault.  A  brief  consideration  of  these  excep- 
tional conditions  may  not  be  amiss. 

Beno- Vesical  Beflex. — It  lias  been  known  since  the  times  of  Val- 
salva that  certain  diseases  of  the  kidney  are  liable  to  produce  a  most 
distressing  irritability  of  the  bladder.  A  common  illustration  of 
this  fact  is  met  with  occasionally  in  cases  of  acute  parenchymatous 
nephritis.  The  onset  of  this  disease  is  sometimes  heralded  by  a 
distressing  and  urgent  frequency  of  micturition.  This  symptom 
usually  passes  away  in  a  few  hours,  to  be  replaced  by  the  character- 
istic features  of  the  disorder,  but  it  is  sometimes  so  severe  while  it 
lasts  as  to  mislead  the  practitioner  into  believing  that  the  patient  is 
attacked  with  acute  cj^stitis.  The  bladder  is  also  sometimes  affected 
in  the  same  manner  in  chronic  diseases  of  the  kidney.  Morgagni  " 
speaks  of  a  patient  who  complained  of  very  little  pain  in  the  region 
of  the  kidneys,  while  he  was  tormented  with  pain  in  the  bladder  so 
excruciating  in  its  intensity  that  five  or  six  physicians  who  attended 
him  entertained  no  doubt  of  the  seat  of  the  disease  being  in  that 
viscus.  On  i:)ost-mortem  examination  no  morbid  appearance  was 
discovered  in  the  bladder,  but  there  were  large  and  ramifying  calculi 
in  the  kidney.  Attention  has  been  particularly  directed  to  this  sub- 
ject by  Sir  B.  Brodie,"  who  records  two  cases  in  which  post-mortem 
examination  completed  the  clinical  history.  The  first  instance  was 
that  of  a  gentleman  w^ho  voided  his  urine  frequently  and  in  quantity 
varying  from  an  ounce  to  an  ounce  and  a  half.  Always  after  making 
water  he  had  a  severe  pain,  lasting  a  few  minutes  and  extending  along 
the  urethra.  The  urine  was  pale,  semi-opaque,  of  an  acid  quality, 
and  when  tested  with  heat  and  nitric  acid  it  was  found  to  be  highly 
albuminous.  Occasionally  small  masses  of  a  substance  resembling 
coagulated  albumin  were  seen  floating  in  it.  He  made  no  complaint 
of  pain  in  the  loins,  he  was  able  to  empty  his  bladder  by  his  own 
efforts,  and  the  urethra  was  free  from  stricture.  There  was  no  cal- 
culus in  the  bladder,  nor  had  any  sand  or  gravel  ever  been  observed 
in  the  urine.  These  symptoms  had  existed  ten  months  and  latterly 
had  gradually  increased.  For  a  short  time  the  urine  had  been  tinged 
with  blood.  In  addition  to  these  local  ailments  the  general  health 
was  much  impaired,  the  patient  had  lost  flesh,  was  languid,  dejected, 
and  of  a  pallid  countenance.  Soon  after  Brodie  was  consulted  the 
urine  again  became  tinged  with  blood.  The  bodily  powers  continued 
to  fail,  and  the  local  symptoms  became  more  urgent.  There  was  a 
total  loss  of  inclination  to  take  food,  the  extremities  became  cold,  the 
pulse  grew  feeble,  and  the  man  died. 

On  examining  the  bladder  after  death  the  kidneys  were  found  to 
be  of  a  dark  color  from  excessive  vascularity,  and  of  a  soft  and  some- 


SYMPTOMS   A€C0MPA2srYING  PYUKIA.  593 

what  brittle  consistence,  the  distinction  between  the  cortical  and  tubu- 
lar portions  being  less  marked  than  under  ordinary  circumstances. 
The  investing  membrane  of  the  kidney  had  a  very  slight  adhesion  to 
the  kidney  itself,  but  it  adhered  closely  to  the  adipose  substance 
of  the  loin.  On  the  surface  of  each  kidney,  and  partly  embedded 
in  its  substance,  were  four  or  five  membranous  cysts,  each  of  the  size 
of  a  large  pea,  and  in  one  of  the  kidneys  there  was  a  similar  one  the 
size  of  a  nutmeg,  completely  embedded  in  the  cortical  substance. 
The  pelvis,  infundibula,  and  ureters  were  not  more  capacious  than 
under  ordinary  circumstances,  but  on  being  split  open  their  internal 
membranous  substance  presented  the  evidences  of  considerable  in- 
flammation. 

It  could  not  be  said  that  the  bladder  was  found  altogether  free 
from  disease,  but  the  morbid  appearances  were  so  slight,  compared 
with  those  observed  in  the  kidney,  that  it  seemed  impossible  to 
doubt  that  the  last-mentioned  organ  had  been  the  seat  of  the  primary 
disease,  and  that  the  bladder  was  affected  only  in  a  secondary  manner. 
It  was  contracted  and  the  muscular  tunic  was  somewhat  thickened, 
but  not  more  so  than  must  have  been  the  case  in  a  person  who  from 
any  cause  had  been  teased  for  a  considerable  time  by  an  incessant 
inclination  to  void  his  urine. 

I  have  encountered  several  instances  lately, — one  of  an  adult  who 
had  such  irritability  of  the  bladder  and  such  agonizing  pain  on  mic- 
turition* that  a  colleague  performed  suprapubic  cystotomy,  but  found 
nothing  to  account  for  the  symptoms.  After  death  a  month  later  the 
entire  left  kidney  was  found  transformed  into  a  sack  of  pus  and  the 
ureter  was  much  thickened  and  almost  impervious.  No  tubercle 
existed  anywhere.  Another  case  was  that  of  a  lady  who  for  many 
years  had  been  tormented  by  frequency  of  micturition  but  by  no  ac- 
tual pain.  Lately  she  had  suffered  from  pain  of  a  very  severe  charac- 
ter in  the  urethra  independent  of  micturition.  The  free  exhibition 
of  morphine  became  necessary.  On  cystocopy  the  bladder  was  found 
to  be  quite  free  and  capable  of  containing  many  ounces,  but  an  in- 
tensely sensitive  right  renal  tumor  was  discovered,  and  this  probably 
was  the  cause  of  the  vesical  symptoms.  It  must  be  remembered, 
however,  that  such  cases  are  undoubtedly  rare,  and  it  is  generally 
the  acid  pus  flowing  over  the  sensitive  neck  of  the  bladder  and  irritat- 
ing it,  or  the  descending  effects  of  tuberculosis,  that  produce  vesical 
symptoms  in  renal  disease.  Conversely  cases  occur  in  which  the 
renal  pelvis  becomes  inflamed  and  sensitive  from  ascending  pyelitis 
of  simple  or  tubercular  character,  and  the  pain  is  felt  mostly  in 
these  more  recently  attacked  parts. 

*  Compare  case  by  M.  Reliquet  quoted  in  the  section  on  haematuria. 
Vol.  I.— :38 


594  FENWICK — DISEASES   OF  THE   UEINE. 

The  following  case  illustrates  tlie  usual  way  in  wliicH  a  renal  dis- 
ease evokes  vesical  irritability : 

A  lady  of  sixty,  who  at  the  age  of  thirty  had  suffered  from  pyuria 
for  seven  years,  and  who  had  complained  for  thirty  years  of  an  aching 
left  kidney,  was  suddenly  seized  with  symptoms  of  epidemic  influenza. 
On  the  third  day  of  the  attack  the  left  kidney  became  swollen  and 
tender  and  pus  again  appeared  in  the  urine  from  which  it  had  been 
so  long  absent.  I  performed  nephrotomy  and  evacuated  and  drained 
a  large  abscess  in  the  cortex ;  there  was  a  small  sinus  communicating 
between  the  sac  and  the  pelvis.  The  urine  promptly  cleared,  but  as 
soon  as  the  drainage-tube  became  blocked,  frequency  of  urination 
and  scalding  were  suffered  from,  but  subsided  on  the  re-establish- 
ment of  the  discharge  into  the  dressings.  This  train  of  symptoms 
happened  on  several  occasions. 

In  tubercular  disease  of  the  kidney,  even  when  the  bladder  is 
slightly  implicated,  the  vesical  symptoms  are  greatly  ameliorated  if 
not  entirely  subdued  by  diverting  the  acrid  pyelitic  pus  through  a 
nephrotomy  wound.  A  well-built  young  fellow  came  to  me  com- 
plaining of  frequency  of  micturition.  This  he  had  had  for  six 
months.  Latterly  he  had  been  unable  to  work  on  account  of  a  grip- 
ing pain  which  used  to  seize  him  in  the  lower  part  of  his  belly  and 
double  him  up.  The  spasm  was  at  once  relieved  by  passing  water. 
Cystoscopy  revealed  an  ulceration  of  the  base  of  the  bladder  on  the 
right  side,  and  rectal  examination  showed  that  the  right  lobe  of  the 
prostate  contained  a  small  deposit  of  tubercle.  In  a  few  weeks  the 
temperature  began  to  oscillate,  the  right  kidney  became  tender. 
Nephrotomy  was  performed,  and  an  abscess  evacuated  from  the  cor- 
tex. All  the  symptoms  of  vesico-urethral  disease  thereupon  disap- 
peared. 

In  rare  cases  the  local  symptoms  are  excited  by  pus  flowing  into 
some  /)art  of  the  conducting  or  collecting  channels,  and  unless  the 
real  source  of  the  pus  is  discovered  the  irritated  organ  will  continue 
not  only  to  mislead  the  medical  attendant,  but  also  to  cause  the  most 
skilful  and  assiduous  treatment  to  miscarry. 

Extea-Urinaey  Sources  op  Pyuria. 

The  source  of  the  pyuria  which  is  occasioned  by  an  abscess  burst- 
ing into  some  part  of  the  urinary  tract  is  usually  located  without 
much  difficulty.  Much  depends  on  the  cross-examination  of  the  pa- 
tient regarding  the  onset  of  the  trouble.  The  symptoms  are  com- 
pounded of  those  specially  evoked  by  the  original  suppuration  and 
of  those  referable  to  that  section  of  the  urinary  apparatus  which 
is  thus  irritated.  A  neighboring  bone  lesion,  some  source  of  inflam- 
mation in  the  female  pelvis,  or  perchance  some  external  pysemic  attack 


EXTEA-UBINAEY   SOURCES   OF   PYURIA.  595 

coupled  with  the  prodromes  of  an  acute  abscess  and  with  the  local 
pain  which  it  evokes,  taken  in  conjunction  with  the  subsequent 
distress  of  that  part  of  the  urinary  tract  wliich  it  is  approaching,  will 
warn  the  practitioner  of  the  probable  cause  and  course  of  the  distur- 
bance. The  abrupt  relief  from  symptoms  of  tension,  coincidently  with 
the  sudden  appearance  of  a  large  quantity  of  jjus  in  hitherto  nor- 
mal urine,  its  subsequent  intermittent  discharge,  and  the  functional 
irritability  of  the  viscus  into  which  it  is  escaping,  will  confirm  the 
diagnosis  of  the  cause  of  the  pyuria  and  the  site  of  the  irruption  of 
the  morbid  product. 

One  of  my  first  cases  for  electric  cystoscopy  was  that  of  a  lady 
suffering  from  profuse  pyuria,  from  a  residual  abscess  due  to  caries 
of  a  rib.     The  history  of  the  patient  was  as  follows : 

Twenty  years  before  consulting  me  she  had  had  strumous  caries 
of  one  of  the  right  lower  ribs.  A  deep  scar  not  far  from  the  right 
renal  region  marked  the  orifice  of  the  abscess  which  then  existed.  In 
January,  1887,  a  sudden  attack  of  pain  in  the  scar  region  was  com- 
plained of,  and  the  symptoms  which  followed  resembled  biliary 
colic.  The  pain  continued  off  and  on,  gradually  descending,  how- 
ever, at  each  attack  somewhat  lower  in  the  abdomen  until  it  became 
very  similar  to  renal  colic.  Eventually  extreme  pain  in  the  bladder, 
and  frequency  of  micturition,  culminated  in  an  acute  cystitis.  Vari- 
ous special  opinions  had  been  taken,  as  regards  both  the  uterus 
and  the  kidney,  but  these  were  very  conflicting  and  for  the  most  part 
undecided.  On  cystoscopy  the  bladder  was  seen  to  be  covered  with 
hemorrhagic  petechias,  which  were  more  numerous  toward  the  orifice 
of  the  right  ureter.  A  dull,  flapping  stream  of  dark,  murky  pus 
issued  sluggishly,  but  at  regular  intervals,  from  the  right  ureteral 
orifice.  The  left  ureteral  opening  was  small,  and  was  ejecting 
healthy  urine.  The  pus  was  evidently  coming  from  the  right  renal 
pelvis,  and  this  taken  in  conjunction  with  the  scar  and  the  history  of  the 
recent  attack,  established  the  diagnosis  of  an  extra-urinary  abscess. 
After  some  months  the  pus  diminished  and  then  ceased,  and  the  lady 
recovered  her  health  and  strength  completely. 

Pycemic  Abscess  in  the  Cellular  Tissue-  of  the  Female  Pelvis,  emptying 
into  the  Bladder  by  a  Minute  Aperture ;  Cystoscopy,  Laparatomy,  Cure. 
— A  lady,  aged  37,  under  Dr.  Valentine  Rees  of  Brecon,  was  sent  me 
for  treatment  for  a  constant  pyuria  and  for  a  most  troublesome 
pain  in  connection  with  the  bladder.  Nine  months  previously  she 
had  had  a  pysemic  attack  with  multiple  abscesses  in  various  joints 
due  to  a  miscarriage.  After  these  had  been  freely  opened  and  had 
healed,  sudden  and  severe  pelvic  pain  with  constitutional  disturbance 
supervened.  This  was  followed  by  great  irritability  of  the  bladder, 
which  culminated  in  the  discharge  of  a  large  quantity  of  pus  in  the 
urine.  The  symptoms  indicated  that  a  pelvic  abscess  had  opened 
into  the  bladder  or  lower  ureters,  but  the  exact  site  was  uncertain. 
Heavy  doses  of  morj)hine  injected  into  the  bladder  became  necessary, 
for  her  life  was  otherwise  unbearable  from  severe  perivesical  and 


596  FENWICK — DISEASES   OF   THE    UEINE. 

urethral  pain  and  from  straining  and  frequency  of  micturition.  The 
morphine  gave  her  perfect  freedom  from  pain  and  ability  to  hold  her 
water  live  hours.  The  urine  was  acid  and  contained  a  variable  amount 
of  creamy  pus,  its  specific  gravity  was  1.020.  Latterly  the  pus  had 
been  noticed  in  the  form  of  long,  thick,  taper-like  pieces.  Cystoscopy : 
Bladder  held  eight  ounces  of  fluid  easily.  The  mucous  membrane 
of  the  posterior  Avail  had  lost  its  sheen,  and  the  muscular  fasciculi 
were  becoming  hypertrophied.  There  was  no  abscess  opening  here. 
The  surface  of  the  left  wall  low  down  was  heaped  up  in  enormous  folds 
of  oedematous  and  inflamed  mucous  membrane.  So  much  was  this 
swollen  that  it  looked  like  a  gelatinous  epithelioma.  The  right  lateral 
wall  was  covered  by  a  similarly  swollen  mucous  membrane,  but  this 
change  from  the  normal  extended  over  a  wider  area  and  was  more 
pronounced.  As  I  was  watching  the  latter  surface  I  saw  a  most  re- 
markable sight.  From  a  minute  crack  in  a  depressed  furrow  between 
two  prominent  folds  a  long  tapeworm-like  body  was  being  gradually 
extruded.  It  was  flat,  white,  and  square-ended.  After  one-third  of 
an  inch  had  protruded,  it  broke  off  by  its  own  weight  and  fell  heavily 
to  the  base  of  the  bladder.  I  followed  it  to  its  resting-place  and 
found  a  small  collection  of  similarly  flattened,  ribbon-like  white  bodies. 
Returning  to  the  crack  I  saw  another  in  the  process  of  being  forced 
out.  My  assistants,  the  anaesthetist,  Mr.  Woodhouse  Braine,  and 
I  watched  this  performance  with  great  curiosity  for  some  time.  It 
never  ceased.  I  washed  out  the  pieces  of  ribbon  and  measured  them. 
They  were  about  one-third  of  an  inch  long,  one-sixteenth  of  an  inch 
thick,  and  about  one-eighth  of  an  inch  v/ide.  The  diagnosis  was  at  once 
established.  An  abscess,  probably  ovarian,  had  burst  into  the  right 
side  of  the  bladder,  and  was  now  probably  obsolescing.  The  patient 
was  advised  to  Avait  three  months  longer,  which  she  did  without  benefit. 
I  therefore,  guided  by  the  cystoscope,  passed  a  probe  through  the  ure- 
thra to  the  vesical  opening  of  the  sac.  As  the  probe  dilated  the  opening 
a  rush  of  thick  fluid  pus  issued,  and  nothing  more  was  seen.  The  pa- 
tient was  at  once  elevated  into  a  Trendelenburg  position,  and  a  median 
laparatomy  was  performed,  the  probe  being  retained  in  position  as  a 
guide.  Adhesions  being  broken  down,  the  intestines  were  lifted  out 
of  the  pelvis  and  an  electric  light  thrown  down  on  to  the  floor  of  that 
cavity ;  it  Avas  then  seen  that  the  abscess  was  beneath  the  peritoneum 
and  unconnected  with  the  ovary.  The  wound  was,  therefore,  closed 
and  the  vesical  opening  of  the  abscess  dilated  with  the  probe  as  far 
as  possible.  An  incision  was  made  through  the  vaginal  roof  on  to  the 
floor  of  the  abscess  Avail  but  not  opening  into  it.  There  was  no  re- 
action, and  the  patient  returned  home  in  three  weeks.  The  subse- 
quent course  Avas  uneventful.  Pus  gradually  diminished,  pain  and 
frequency  of  micturition  ceased,  and  the  patient  reported  herself 
cured  in  about  four  months'  time. 

Hydatid  Sac  Bursting  into  the  Left  Renal  Pelvis,  Subsequent  Suppuror- 
tion. — Hydatid  sacs  in  the  cellular  tissue  in  the  neighborhood  of  the 
kidney  evince  a  singular  tendency  to  burst  into  the  pelvis  of  that 
viscus.  Occasionally  they  suppurate,  probably  because  of  th-e  pro- 
pinquity of  the  colon.     One  patient,  of  seven  cases  of  urinary  hy- 


EXTRA-URINARY  SOURCES  OF  PYURIA.  597 

datids,  brought  with  him  an  eight-ounce  bottle  of  pus,  cysts,  and 
thin  gruel-like  urine,  as  a  sample  of  what  he  had  passed  daily  for 
some  weeks.  He  had  had  an  hydatid  cyst  the  size  of  a  foetal  head, 
which  occasionally  emptied  itself  into  the  renal  pelvis,  for  thirty-one 
years.  A  month  previous  to  consulting  me  the  contents  of  the  sac 
had  suppurated,  and  he  began  to  pass  more  cysts  than  he  had  done 
during  the  thirty  years  of  his  illness.  He  refused  operation,  and  got 
quite  well  under  ordinary  medicine,  the  colic  and  fixed  pain  ceasing, 
the  urine  clearing,  and  the  sac  contracting  until  it  was  quite  small. 

External  Pyoemia,  Acetabular  Abscess-  Bursting  into  the  Bladder 
Three  Times,  Scar  in  Bladder  Seemvith  Cystoscope. — A  young  fellow, 
aged  30,  was  sent  to  me  by  Dr.  Ayling  for  an  acute  attack  of  cysti- 
tis. In  1878  he  suffered  from  "  pyaemia"  in  Germany,  his  left  hip 
and  right  knee  being  affected  most  severely,  and  ankylosing.  In 
1884  the  old  abscess  in  the  left  hip  opened,  and  in  1885  an  abscess 
formed  apparently  on  the  inner  side  of  the  acetabulum,  for  the  pa- 
tient states  it  burst  into  his  bladder  and  discharged  pus  and  blood 
into  the  urethra,  the  jjain  ceasing  at  the  same  time  in  the  hip.  These 
abscesses  have  formed  three  times,  and  they  have  always  evacuated 
themselves  by  the  same  route.  In  1886  an  abscess  dischagred  by  the 
rectum  and  a  piece  of  bone  came  out.  Apparently  this  was  the  con- 
clusion of  the  disturbance,  for  he  has  since  been  in  perfect  health 
until  the  attack  for  which  he  presented  himself  to  me. 

A  month  previous  to  seeing  me  he  began  to  suffer  suprapubic  pain 
after  passing  water.  It  was  not  in  the  penis  at  first.  There  was  no 
frequency  of  urination  and  no  blood.  A  week  before  seeing  me  he  was 
suddenly  seized  while  micturating  with  a  severe  pain  at  the  inner  side  of 
the  suprapubic  area  and  along  the  penile  urethra  to  the  glans.  This 
continued,  became  constant,  and  was  quite  independent  of  micturition. 
He  urinated  every  three  hours  in  the  day,  and  once  at  night;  when 
the  call  came  it  was  urgent  but  not  imperious ;  the  stream  was  twisted 
and  curled.  He  was  in  terror  lest  another  abscess  was  forming.  The 
left  hip  was  ankylosed  and  covered  with  deep  scars  both  before  and  be- 
hind. The  urine  was  acid,  1.020,  straw-colored,  clear,  contained 
one-eighth  albumin,  irregular-shaped  uric-acid  crystals,  but  no  casts. 
With  the  electric  cystoscope  I  found  he  had  a  well-marked  patch  of 
sessile  warty  growth,  the  size  of  a  threepenny  bit,  on  the  left  side  of 
the  lateral  wall  low  down.  This  patch  was  situated  on  a  healthy  base, 
and  the  neighborhood  was  uninflamed.  The  rest  of  the  bladder  was 
healthy.  From  his  history  and  the  unusual  appearance  of  this  splash 
of  warty  growth,  I  felt  justified  in  considering  that  it  was  the  relic  of 
an  irritation  which  had  approached  the  bladder  from  without,  and 
probably  marked  the  site  of  the  opening  of  the  abscess  which  had 
burst  thrice  into  the  bladder  from  the  neighborhood  of  the  left  hip. 

Fallacy. — Cases  are  on  record  of  psoas  abscess  breaking  into  the 
bladder,"  and  even  carrying  pieces  of  bone  into  that  viscus,  but  it  is, 
I  believe,  comparatively  uncommon  for  these  abscesses  to  break  into 


598  FENWICK — DISEASES   OP  THE   URINE. 

the  ureters  or  kidney  pelvis,  for  if  tliey  do  affect  tliis  urinary  channel 
it  is  rather  by  occluding  the  ureter,  and  by  producing  disorganization 
of  the  kidney/"  In  dealing  with  these  cases  of  angular  curvature  of 
the  dorsal  spine,  it  is  unwise  to  conclude  hastily  that  urinary  symp- 
toms betoken  the  irruption  of  pus  into  the  tract  from  a  spinal  collec- 
tion ;  it  should  be  remembered  that  frequency  of  micturition  and  pain 
at  the  end  of  the  penis,  together  with  small  amounts  of  pus  in  acid 
urine,  are  caused  by  independent  tubercular  disease  in  the  renal  sub- 
stance. Still  more  unlikely  is  a  psoas  or  an  iliac  abscess  which  pro- 
jects into  the  groin  or  loin  to  affect  the  urinary  passages,  for  it  has 
obviously  made  its  way  in  another  direction.  I  have  made  two  post- 
mortems which  illustrate  this. 

A  man  aged  50  developed  a  psoas  abscess  in  his  left  thigh  which 
had  emanated  from  caries  between  the  fourth  and  fifth  lumbar  verte- 
brae, a  curvature  at  this  spot  having  existed  for  fifteen  years.  Pus 
was  passed  with  the  urine.  This  psoas  collection  was  opened,  but 
the  pus  in  the  urine  did  not  diminish.  On  post-mortem  the  left 
kidney  was  found  entirely  destroyed  by  tubercular  disease,  and  the 
left  psoas  abscess  had  no  connection  with  either  the  ureter  or  pelvis 
of  the  kidney. 

A  man  aged  51  presented  himseK  with  a  large  psoas  abscess 
the  size  of  a  child's  head  simulating  inguinal  hernia  of  the  left  side. 
The  urine  was  acid  and  contained  much  pus,  the  specific  gravity  was 
1.010.  The  psoas  abscess  was  opened.  On  the  death  of  the  man 
from  hectic  and  exhaustion  a  few  days  after,  a  post-mortem  was  made 
and  the  abscess  was  tracked  to  the  caries  of  the  first  sacral  and  last 
lumbar  vertebrae.  It  was  quite  unconnected  with  the  urinary  tract. 
The  left  ureter  was  enormously  thick,  its  canal  was  patent,  and  the 
mucous  membrane  was  tubercular.  The  renal  pelvis  and  one  or  two 
calyces  about  the  middle  of  the  kidney  were  also  implicated,  while  the 
bladder  was  patched  over  with  crude  tubercle  and  superficially  ulcer- 
ated. The  trigone  and  adjoining  posterior  wall  had  been  cleanly 
dissected  up.  The  right  kidney  was  healthy.  Probably  there  was 
direct  contagion  from  the  psoas  to  the  ureter,  through  the  medium  of 
the  Ij^mphatics. 

The  Chief  Urinary  Diseases  Producing  Pyuria. 

Presupposing  that  the  source  of  the  pus  has  been  determined,  the 
exact  cause  for  its  production  must  be  decided  upon.  This  necessi- 
tates a  brief  consideration  of  the  chief  symptoms  which  accompany 
pus  emanating  from  (1)  the  renal  pelvis,  (2)  the  bladder,  and  (3) 
the  urethra.  Seeing,  however,  that  the  pyurias  of  the  lower  urinary 
tract  come  more  into  the  province  of  the  surgeon,  attention  will 
rather  be  paid  to  the  pyelitic  diseases,  and  the  reader  is  referred  to 
the  sections  on  diseases  of  the  bladder  and  of  the  prostate  for  a  detailed 
account  of  cysto-prostatic  disorders. 


CHIEF  URINARY  DISEASES  PRODUCING  PYURIA.  599 

The  inflammatory  diseases  of  the  pelvis  and  kidney  are  prop- 
erly embraced  by  the  terms  pyelitis  and  pyelonephritis,  while 
pyonephrosis  is  retained  to  indicate  an  accidental  stage  of  either, 
being  dependent  on  intermittent  obstruction  to  the  outlet  from  these 
inflamed  parts. 

Pyelitis  is  either  primary  or  secondary.  In  the  former  it  has 
originated  in  the  kidney  or  its  pelvis,  and  in  the  latter  it  has  extended 
to  this  section  from  the  lower  urinary  tract.  It  is  of  importance  to 
obtain  a  correct  history  of  the  symptoms  marking  the  onset  of  pyelitic 
pyuria,  for  a  distinction  between  primary  and  secondary  pyelitis, 
which  is  often  possible  by  means  of  this  knowledge,  is  a  matter  of 
much  surgical  moment. 

Primary  pyelitis  may  arise  either  from  the  chemical  action  of  drugs, 
such  as  cantharides,  turpentine,  balsams,  diuretics,  or  from  that  of 
the  products  of  micro-organisms  of  general  diseases,  such  as  typhus, 
pyaemia,  influenza,  tuberculosis,  which  irritate  the  kidney  substance 
and  mucous  membrane  of  the  pelvis,  as  they  are  eliminated  through 
these  great  depuratory  centres.  It  may,  moreover,  be  provoked  by 
mechanical  causes,  as  is  seen  in  a  hydronephrosis  becoming  fouled  by 
the  bacilli  of  the  adjoining  colon.  Secondary  pyelitis  is  evoked  by 
the  direct  extension  upward  of  inflammation  from  the  bladder, 
prostate,  or  urethra,  such  as  obtains  in  vesical  calculus,  obstructing 
vesical  growth,  enlarged  prostate,  stricture,  and  gonorrhoea.  It  is 
said  that  the  urine  in  primary  pyelitis  is  usually  acid  and  will  often 
remain  so  for  days,  while  that  in  secondary  pyelitis  is  neutral  or 
alkaline,  and  that  it  rajjidly  decomposes.  Moreover,  Ultzmann 
asserts  that  primary  pyelitis  is  never  accompanied  by  frequent  or 
painful  micturition,  while  the  pyelitis  which  is  propagated  from  the 
bladder  or  prostate  usually  is  accompanied  by  these  symptoms.  I 
am  sure  that  this  cannot  be  accepted,  for  pyelitis  produces  an  irri- 
tability of  the  lower  urinary  tract  either  reflexly  or  directly  by  the 
acrid  discharge  from  the  renal  pelvis  irritating  the  neck  of  the  bladder 
in  its  exit.     ( Fide  Reno-vesical  Reflex,  p.  592.) 

Acute  Primary  Pyelitis. — The  general  diseases  which  affect  the 
pelvis  of  the  kidney  and  evoke  a  pyuria  are  many  and  various.  In 
the  acute  form  a  mere  catarrh  may  be  set  up,  or  multiple  foci  of 
suppuration  in  the  substance  of  the  kidney  may  be  provoked  and 
a  true  pyelonephritis  is  the  result.  These  small  abscesses  may 
amalgamate  and  form  large  cortical  or  medullary  abscesses  and 
burst  into  the  pelvis.  The  most  marked  general  symptoms  are  severe 
rigors,  high  fever,  and  lumbar  pain.  The  urine  is  scanty,  albumin- 
ous, and  purulent. 

Chronic  Primary  Pyelitis. — This  usually   presents  three  stages, 


600  FENWICK — DISEASES   OF  THE   UEINE. 

onset  symptoms,  formation  of  tumor,  and  stinking  decomposition  of 
its  contents. 

Onset  Symi^toms. — Tlie  onset  symjjtoms  vary  greatly.  In  some 
cases  there  is  no  pain  until  long  after  pus  is  noticed  in  tlie  urine. 
Usually,  however,  there  is  an  aching  in  one  loin  or  the  back,  a  depress- 
ing sense  of  weakness  in  the  lumbar  region,  which  the  patient  cannot 
account  for,  or  which  may  be  connected  with  a  blow  on  the  loin. 
Not  infrequently  a  marked  polyuria  is  present.  If  the  pyelitis  is 
caused  by  a  round  stone  which  occasionallj^  drops  on  the  mouth  of 
the  ureter,  or  by  some  other  form  of  ureteric  obstruction,  intermit- 
tent colics  are  suffered  from.  Hsematuria,  vesical  irritability,  and 
vesical  colic  are  often  coincident  symptoms.* 

Enlargement  of  Kidney,  or  Formation  of  a  Tumor  (Pyonephrosis) . — 
I  believe  the  kidneys  are  more  or  less  swollen  in  most  cases  of  pri- 
mary pyelitis,  the  enlargement  varying  according  to  the  distention  of 
the  peMs  or  the  calyces.  Even  in  cases  of  calculi  in  which  the  ure- 
ters are  permanently  patent  and  the  upper  tract  is  well  di-ained,  the 
kidney  itself  is  enlarged  and  the  surrounding  fatty  tissue  matted  with 
inflammatory  products  which  add  to  the  apparent  bulk  of  the  organ. 
The  appreciation  of  the  actual  size  of  the  tumor  differs,  of  course, 
with  the  rigidity  and  adiposity  of  the  abdominal  wall. 

DecomiDosition  of  Residual  Pyelitic  Urine. — Sooner  or  later,  if  the 
case  i)rogresses  and  is  not  of  a  tubercular  type,  the  fluid  contents  of 
the  kidney  or  its  pelvis  become  fouled  from  the  adjoining  colon  or  by 
vesical  sepsis,  introduced  b.y  the  surgeon,  ascending  to  the  kidney. 
The  laudable  pus  which,  prior  to  this,  separated  rapidly  from  the 
acid  urine  now  becomes  transformed  into  a  thick,  solid  muco-pus, 
very  similar  to,  but  probably  more  offensively  fsecal  in  its  odor  than, 
the  ammoniacal  filth  which  is  passed  by  patients  suffering  from  ad- 
vanced vesical  disease.  Microscopically,  although  the  secretion  may 
still  retain  its  acid  character,  large  crj^stals  of  the  triple  phosphates  are 
present,  their  edges  being  eroded  and  nipped  out  by  the  acid  tide 
which  the  healthy  kidney  pours  into  the  bladder.  Perhaps  the  car- 
dinal symptoms  of  primary  pyelitis  are  the  discharge  of  acid  pus  in 
more  or  less  abundance,  the  formation  of  a  definite  renal  swelling 
which  is  tender  on  deep  pressure,  and  the  detection  of  fluctuation  in 
the  same  if  the  collection  is  a  large  one.  If  a  constant  irritant  is 
present,  such  as  a  stone,  the  tenderness  is  accentuated,  and  should 
the  canal  of  the  ureter  draining  a  unilaterally  distended  kidney  become 

*  The  cystoscope  points  to  the  symptoms  being  produced  by  an  exaggeration  of 
the  normal  ureteric  wave  passing  on  to,  and  exciting,  the  bladder  muscles.  It  is 
probably  analogous  to  rectal  tenesmus,  which  occurs  in  35  per  cent,  of  ileo-caecal 
intussusception  (Fitz). 


CHIEF  URINAEY  DISEASES  PRODUCING  PYURIA.  601 

temporarily  obstructed  from  any  cause,  as  is  not  unusual,  the  pus 
disappears  for  a  time  and  the  renal  tumor  and  tenderness  increase, 
but  both  diminish  again  as  the  pent-up  pus  suddenly  escapes  along 
the  unchoked  channel.  In  conjunction  with  these  symptoms,  there 
are  others  dependent  on  absorption,  infection  from  the  colon,  or  ex- 
haustion :  rigors,  often  quotidian  (Roberts) ,  fever  of  a  hectic  grade, 
loss  of  flesh,  and  diarrhoea. 

The  most  usual  forms  of  chronic  primary  j)yelitis  are  the  calcu- 
lous, the  tubercular,  and  the  traumatic,  with  or  without  ureteral  ob- 
structions. The  reader  must  be  referred  to  the  article  which  deals 
fully  with  these  diseases,  but  the  following  brief  remarks  on  their 
salient  features  and  the  accompanying  illustrative  cases  are  not  irrele- 
vant or  beyond  the  scope  of  this  article. 

Calculous  Pyelitis. — The  following  case  illustrates  the  gradual  in- 
crease of  a  calculus  in  the  renal  pelvis,  its  irritation  of  the  mucous 
membrane  producing  a  symptomless  pyuria,  the  gradual  onset  of 
perinephritic  inflammation  and  adhesions,  and  the  final  decomposi- 
tion of  urine  in  the  renal  calyces.  This  train  of  changes  occurred 
with  renal  swelling  but  without  pelvic  distention,  because  no  marked 
obstruction  to  the  corresponding  ureter  existed. 

Case  :  Calculous  Pyelitis:  of  Twelve  Years'  Standing,  Decomposition 
of  Urine,  very  few  Symptoms,  Nephrectomy,  Cure. — Twelve  years  ago 
the  patient  fjassed  two  pieces  of  stone  from  the  right  kidney,  since 
which  time  he  has  always  suffered  a  little  pain  in  that  organ  of  a  dull 
character,  suflicient  to  cause  him  to  be  aware  that  he  had  a  kidney. 
He  has  not  had  hsematuria  since  the  beginning  of  the  trouble.  He 
applied  for  relief  because  his  urine  had  been  smelling  foully  for  the 
last  year,  and  he  wet  his  bed  at  night.  His  urine  was  very  fetid ; 
its  specific  gravity  was  1.020.  Two  per  cent,  of  urea  was  present. 
The  urine  was  murky,  depositing  a  thick  layer  of  pus,  and  a  fine 
layer  of  blood.  The  right  kidney  was  somewhat  enlarged  and  tender. 
Over  the  anterior  region  of  the  kidney  there  was  a  definite  muscular 
swelling,  which  disappeared  when  the  patient  was  under  an  anaesthetic, 
and  was  supposed  to  be  due  to  refiex  irritation  from  the  disease 
beneath.  I  removed  the  right  kidney  by  the  lumbar  route,  after 
considerable  difiiculty  had  been  experienced  from  the  very  dense  ad- 
hesions which  were  present.  The  entire  jjelvis  was  occupied  by  a 
large  branched  phosf)hatic  stone,  which  had  so  irritated  the  kidney 
as  to  produce  perinephric  matting.  The  kidney  was  riddled  with 
small  walnut-sized  cavities,  containing  pus  and  urine.  The  patient 
recovered  promptly  and  the  nocturnal  enuresis  disappeared. 

Calaihus  Pyonephrosis. — It  is  remarkable  how  tolerant  the  dis- 
tended and  inflamed  pelvis  of  the  kidney  proves  itself  to  be.  Large 
stones  are  carried  almost  without  any  symptom  pointing  to  resentment 
of  their  presence.     This  is  especially  noticeable  in  the  female  kidney. 


602  FENWICK — DISEASES  OP  THE  URINE. 

Hsematuria  is  very  seldom  observed  wlien  pyuria  is  marked,  and 
rarely  is  there  any  complaint  of  pain,  beyond  a  dull  kidney-ache. 
When,  however,  an  acute  pyelitis  is  grafted  on  a  chronic  form,  the 
suffering  may  be  of  an  extreme  character.  Women  seem  particularly 
prone  to  the  formation  of  calculi  in  a  distended  renal  pelvis.*  The 
calculus  in  such  cases  may  be,  and  I  suspect  often  is,  the  result  and  not 
the  cause  of  the  distention.  The  latter  may  be  due  to  intermittent 
uterine  tugs,  and  other  forms  of  uterine  pressure,  e.g.,  pregnancy, 
causing  first  a  latent  hydronephrosis,  and  secondarily  a  pyone- 
phrosis. It  will  be  found  that  75  per  cent,  of  cases  of  calculous  pyo- 
nephrosis operated  ujDon  were  females,  and  that  nearly  all  these  had 
a  well-developed  renal  tumor. 

Mr.  Day '"  has  removed  a  large  right  renal  stone,  weighing  1,331 
grains,  from  a  woman,  age  thirty-two.  The  symptoms  had  existed 
fourteen  years,  and  they  consisted  in  occasional  pain  in  the  right 
loin,  lasting  perhaps  three  days,  with  intervals  of  complete  freedom. 
Apparently  a  right  renal  tumor  had  been  noticed  only  a  year,  and 
coincidently  with  its  appearance  was  the  change  of  the  urine  to  a 
thick,  slimy  condition.  The  right  lumbar  incision  was  made,  and 
the  stone,  which  was  mainly  phosphatic,  was  successfully  removed  in 
two  sittings.  Probably  this  is  one  of  the  largest  calculi  removed 
from  the  kidney. 

Mr.  Bloxam  recently  showed  a  soup-plate  full  of  large  calculi 
(13  ounces)  which  were  removed  by  him  through  a  lumbar  incision 
from  a  woman  who  presented  few  symptoms  of  the  disease." 

Tubercular  Pyelitis. — Usually  primary  tubercular  pyelitis  is  a 
true  tubercular  pyelonephritis,  for  it  is  rare  for  the  pelvis  to  be 
affected  without  the  renal  tissue  becoming  rapidly  implicated,  and 
vice  versa. 

Cases  have  been  mentioned  in  the  section  on  Hsematuria  (tuber- 
cular disease  of  the  kidney).  Judging  by  Brodeur's  statistics,  it 
would  seem  that  women  were  more  often  affected  by  this  disease 
than  men.  This,  however,  is  not  so.  I  believe  women  are  more  prone 
to  suppurative  renal  tumors  than  are  men,  on  account  of  the  greater 
chance  of  pressure  on  the  lower  ureters,  but  most  of  my  renal  tubercular 
cases  have  occurred  in  males.  I  believe  that  a  large  number  of  the 
cases  of  suppurative  pyelonephritis  occur  in  patients  with  tubercu- 
lar tendencies,  and  in  these  a  slight  accident  or  subacute  ascending 
pyelitis  is  sufficient  to  cause  rapid  destruction  of  renal  tissue  of 
weakened  resistance.    The  pyelitis  of  primary  renal  tuberculosis  may 

*  Calculous  pyelonephritis,  49  females,  17  males ;  suppurative  non-tubercular 
pyelonephritis,  29  females,  14  males  (Brodeur). 


CHIEF   URINARY  DISEASES  PRODUCING  PYURIA.  603 

remain  subacute  for  some  months,  being  merely  accompanied  by  in- 
termittent attacks  of  slight  pyrexia  and  pain.  The  urine  is  acid,  low 
in  specific  gravity,  and  murky  with  pus,  and  -contains  albumin  in 
excess  of  what  can  be  accoilnted  for  by  the  pus  present.  Even  at  this 
stage  rabbits  can  be  successfully  inoculated  with  it,  but  the  bacillus 
is  difiicult  to  discover,  unless  the  tuberculosis  is  very  acute.  The 
kidney  is  invariably  tender,  but  unless  it  has  been  aggravated  into  re^ 
sentment  by  vesical  washing,  it  does  not  rapidly  enlarge.  Given, 
however,  a  septic  condition  of  the  bladder,  pus  rajoidly  increases,  the 
kidney  enlarges,  and  often  perinephritis  is  superadded. 

Traumatic  Pyelitis. — Pus  appears  for  a  short  time  after  any  blow 
upon  the  kidney  of  force  sufficient  to  produce  hsematuria,  and  will 
continue  in  direct  proportion  to  the  extent  of  the  injury.  Usually, 
however,  if  the  lower  urinary  tract  does  not  become  seriously  inflamed 
the  pus  will  disappear  as  health  is  regained.  Some  cases  of  trau- 
matic renal  pyuria  prove  extremely  obstinate,  and  in  these  it  may  be 
that  a  calculus  has. formed  or  a  marked  tubercular  inheritance  or  in- 
fection causes  a  sluggish  healing  of  the  renal  wound.  Occasionally  a 
perinephritis  is  first  produced  by  the  blow  and  the  collection  of  pus 
bursts  into  the  pelvis  of  the  kidney.  This  is,  I  believe,  rare.  I 
have  recently  performed  nephrectomy  for  a  pyelitis  following  a  blow. 

A  young  man,  aged  24,  whose  father  and  brother  were  reported 
as  having  died  of  phthisis,  presented  himself  with  a  large  pyone- 
phrosis, which  was  visibly  occupying  the  left  side  of  abdomen.  Six 
months  previously  he  was  struck  violently  in  the  left  loin,  and  he 
attributes  the  cause  of  the  present  swelling  to  the  blow.  He  did 
not  pass  blood  and  he  never  noticed  his  water  murky  until  recently, 
when  its  very  offensive  smell  and  thickness  prompted  him  to  seek 
relief.  The  urine  was  turbid  and  very  fetid,  it  was  acid  in  reaction, 
specific  gravity  1.019,  and  contained  albumin  and  one-third  pus. 
On  my  seeing  him  a  day  or  two  after  admission,  he  was  just  beginning 
to  suffer  from  pain  in  the  loin,  and  I  was  struck  with  the  coincidence  of 
rapid  enlargement  of  the  tumor  and  decomposition  of  the  urine  with 
normal  temperature.  No  vesical  or  urethral  intervention  had  been  at- 
tempted. I  learned  that  he  had  had  an  obstinate  attack  of  profuse 
diarrhoea  three  weeks  ago,  which  may  have  been  the  consequence  or 
the  cause  of  the  fetid  character  of  the  pyonephrosis.  Until  the  tumor 
appeared  he  could  retain  his  water  for  five  or  six  hours,  but  since 
then  he  had  been  forced  to  micturate  every  hour ;  he  did  not  rise 
at  night.  On  performing  lumbar  nephrotomy,  I  evacuated  eighty 
ounces  of  the  most  nauseous  puriform  urine  from  a  superficial  renal 
sac  and  found  another  large  cyst  deeper,  which  I  tore  into  by  means 
of  a  large  probe.  A  still  deei)er  though  smaller  collection  was  found. 
I  therefore  sli])7)ed  the  kidney  out  of  its  capsule,  tied  off  the  pedicle 
and  removed  it.  There  was  no  stone ;  the  entire  kidney  had  been 
transformed  into  an  enormous  loculated  thin-walled  sac.    The  ureter 


604  PENWICK — ^DISEASES   OF  THE   UEINE. 

whicli  was  not  dilated  was  tied  off,  and  dropped  back.  The  urine 
cleared  immediately,  it  was  passed  at  a  long  intervals,  and  the  wound 
rapidly  healed. 

Secondary  Pyelitis. — Probably  the  most  usual  cause  for  pyelitis 
lies  in  an  upward  extension,  along  the  ureters,  of  the  inflammation 
which  has  originated  in  the  bladder,  prostate,  or  urethra,  and  it  is  in 
these  cases  that  the  diagnosis  of  pyelitis  is  so  difficult  and  uncertain. 
It  is  often  impossible  to  state  with  certainty  how  much  of  the  pus  is 
contributed  by  the  original  disease,  and  how  much  hy  that  grafted 
on  to  the  secondary  extension.  It  is,  therefore,  in  this  class  that  so 
many  mistakes  are  unwittingly  made,  and  attention  and  treatment  are 
directed  to  the  bladder  ailment  long  after  that  viscus  has  become  a 
subsidiary  factor  as  a  pus  producer.  The  cystoscope,  in  the  hands 
of  skilled  workers,  certainly  enables  a  correct  diagnosis  to  be  made, 
but  in  general  practice  the  cystoscope  is  impractical,  and  clinical 
grounds  are  all  that  can  be  depended  on.  These  are  frequently  un- 
satisfactory and  misleading.  The  ureter,  pelvis,  and  kidney  may  be- 
come affected  from  tlie  bladder  either  rapidly  or  gradually. 

Rapid  Invasion  of  the  Renal  Pelvis  from  a  Bladder  Source. — A 
rapid  invasion  of  the  renal  pelvis  is  comparatively  uncommon,  and 
fortunately  so,  for  it  is  often  fatal.  Usually  the  extension  is  slow  in 
progress.  Probably  a  rapid  invasion  greatly  depends,  in  non-tubercu- 
lar cases,  on  the  previous  health  of  the  ureters  and  kidneys;  e.g.,  pro- 
longed lithiasis  acts  as  an  injurious  depressor  to  the  power  of  resist- 
ance of  these  organs  to  septic  invasion.  The  barrier  which  the  tonic 
muscles  of  the  ureter  oppose,  to  ascending  changes  is  an  important 
factor  in  resisting  invasion,  for  if  the  ureters  have  become  dilated  by 
backward  pressure,  and  the'  mucous'*membrane  is  proportionately 
thinned,  the  septic  wave  may  ascend  in  a  few  hours  and  a  fatal  re- 
sult ensue. 

The  most  marked  and  the  most  frequent  examples  of  rapid  invasion 
are  to  be  found  in  consequence  of  injudicious  instrumentation,  in 
vesico-prostatic  tuberculosis,  in  uratic  stones  in  gouty  patients  over 
fifty,  and  in  the  advanced  vesical  atony  of  prostatic  enlargement.  It 
is  rare  that  gonorrhoeal  extension  to  the  kidney  is  of  the  rapid  type, 
but  I  have  met  with  a  few  instances  of  undoubted  chronic  invasion. 
The  features  and  dangers  of  this  aspect  of  these  three  diseases  may 
be  briefly  illustrated  by  the  following  cases  and  remarks. 

Acute  Ascending  Pyelitis  from  a  Tuhercidar  Vesical  Source. — The 
presence  of  a  secondary  tubercular  pyelitis  can  only  be  expressed  by 
the  suppurative  destruction  it  causes  in  the  kidney.  The  latter  is 
probably  affected  previously,  though  latently,  by  the  lymphatics 
along  the  ureter. 


CHIEF   URINARY   DISEASES   PRODUCING   PYURIA.  605 

Tlie  septic  invasion  following  instrumentation  of  the  bladder  is 
merely  a  spark  to  ready  tinder.  Vesical  tuberculosis,  however, 
differs  in  its  resentment  to  instrumentation  according  to  the  sex 
of  the  patient,  and  the  stage  of  the  disease  in  which  this  in- 
strumentation is  commenced.  The  tubercular  bladder  of  a  female 
patient  may  be  lightly  sounded  and  even  washed  out  with  compara- 
tive impunity  in  the  first  few  months  of  the  onset  of  the  disease,  and 
this  without  much  risk  being  incurred.  There  comes,  however,  a 
tim^  unmarked  by  danger  signals,  in  which  washing  out  of  the  blad- 
der is  fatal  to  the  integrity  of  the  kidney,  though  the  sound  may  still 
be  used  without  inducing  this  untoward  result.  Still  later  the  sound 
is  dangerous. 

In  the  male  the  sound  is  as  dangerous  as  the  catheter  and  wash- 
ing, in  all  cases  loliere  the  prostate  is  nodular  and  the  bladder  is  in- 
jlamed.  Either  instrument  is  sooner  contra-indicated  than  in  the 
female.  The  actual  invasion  is  usually  along  one  ureter,  and  differs 
from  the  other  ascending  forms  to  be  immediately  described,  in  that 
one  kidney  only  suffers  and  that  by  a  localized  abscess.  Later  still 
where  both  kidneys  have  been  crippled,  and  the  ureters  are  involved, 
the  mere  introduction  of  a  bougie  through  the  prostatic  urethra  is 
sufficient  to  Cause  rapid  and  fatal  suppression.  I  regret  that  I  can 
furnish  many  examples,  but  the  following  will  suffice : 

Left  Renal  Tuberculosis,  Instrumentation,  Acute  Pyelitis,  Renal  Ab- 
scess, Nephrotomy. — I  saw  in  consultation  a  patient,  who  had  applied 
a  few  days  previously  to  a  well-known  surgeon  for  the  relief  of  a  fre- 
quency of  micturition  and  of  a  dull  fixed  jjain  in  the  left  kidney.  .The 
irritability  of  the  bladder  was  not  excessive,  and  the  urine  was  quite 
clear,  so  he  was  sounded  for  stone  in  the  consulting-room.  Two  hours 
afterward  his  temperature  suddenly  rose  without  a  rigor,  the  dull 
pain  in  the  left  loin  increased  in  severity,  and  the  urine  passed  was 
slightly  murky.  The  temperature  remained  above  102°  and  he  began 
to  lose  ground  rapidly.  The  left  kidney  was  slightly  enlarged  and 
intensely  sensitive  to  pressure.  The  urine  contained  pus  to  a  small 
amount;  it  was  acid,  i)ale,  specific  gravity  1.010.  On  inquiry  I  learnt 
there  was  a  family  history  of  diabetes,  and  that  three  of  his  imme- 
diate relatives  had  died  of  x)hthisis.  Nephrotomy  was  performed. 
The  surface  of  the  kidney  was  seen  to  be  of  a  mottled  yellow,  and  a 
quantity  of  pus  and  white  flaky  caseous  material  was  evacuated  from 
the  cortex  of  the  kidney.  Obviously  a  tubercular  deposit  had  broken 
down  under  the  influence  of  an  ascending  pyelitis.  He  was  tempo- 
rarily relieved. 

Ascending  Pyelitis  due  to  Instrumentation  in  Gouty  Kidneys. — It  is 
known  that  kidneys  which  habitually  cast  off  uratic  deposits  become 
less  effective  as  time  goes  on,  and  less  able  to  withstand  sudden 
reflex  shocks  and  inflammatory  invasions,  but  the  caustic  effect  which 


606  FENWICK— DISEASES   OF  THE   URINE. 

a  constant  stream  of  uric  acid,  or  of  its  salts,  produces  upon  the  urinary 
mucous  membrane  is  hardly  appreciated  by  the  profession.  This 
is  probably  because  the  parts  upon  which  most  of  our  pathological 
knowledge  is  based  are  examined  after  death  when  congestion  has 
disappeared,  and  all  granulation  of  surface  has  become  invisible  from 
post-mortem  change.  It  is  quickly  realized,  however,  if  the  bladders 
of  those  passing  uric  acid  are  examined  with  the  cystoscope.  The 
vesical  neighborhood  of  the  ureter  is  reddened,  the  surface  is  blurred, 
and  often  granular.  It  is  highly  probable  that  these  conducting 
channels  are  affected  in  a  similar  way.  It  is  abundantly  proved  that 
such  changes  in  the  urethra  predispose,  on  the  slight  provocation  of 
an  error  in  diet,  of  a  chill,  or  the  traumatism  of  a  connection,  to 
the  production  of  urethritis.  The  entire  urinary  tract  of  a  patient 
who  has  been  voiding  uratic  urine  for  years  is  nothing  more  than 
surgical  tinder. 

Let  a  typically  gouty  man,  over  fifty  years  of  age,  with  clear  sterile 
urine,  suddenly  get  a  small  renal  calculus  trapped  behind  a  large 
prostate,  and  he  is  frequently  in  more  danger  from  the  action  of  a 
rough,  unskiKul  surgeon  than  from  his  stone.  After  litholapaxy  the 
temperature  rises,  pus  appears  in  the  urine  from  cystitis,  ascending 
pyelitis  supervenes,  and  the  patient  may  even  succumb  from  renal 
suppuration. 

Acute  Ascending  Pyelitis  FoUoiving  the  Removal  of  Large  Amow^ts  of 
Urine  in  Prostatic  Enlargement. — Instead  of  laboring  to  excrete  salts  as 
in  the  previous  disease  the  renal  tissue  may  become  so  impoverished  by 
unsuspected  backward  pressure  from  an  enlarged  prostate  that  water 
only  filters  through.  A  patient  about  sixty  years  of  age  may  be  a 
martyr  to  aggravated  dyspepsia  and  increasing  weakness,  the  excre- 
tory needs  of  the  body  being  barely  maintained  by  the  insufficient 
renal  function.  Suddenly  the  medical  attendant  discovers  the  blad- 
der well  above  the  umbilicus,  and  disregarding  the  three  great  danger 
signals  which  accompany  the  pus  in  the  urine — morning  vomiting, 
intense  thirst,  abundant  urine  of  a  low  specific  gravity — he  passes  an 
instrument  and  withdraws  all  or  most  of  the  urine.  At  once  the  mild 
cystitis  is  aggravated,  or  if  it  was  not  present  before  it  now  appears, 
acute  ascending  pyelitis  ensues,  and  renal  syncope  supervenes  in 
from  seven  to  ten  days. 

Gradual  Invasion  of  the  Renal  Pelvis  from  a  Lower  Source. — Usually 
the  method  of  invasion  of  ascending  pyelitis  is  chronic  and  progres- 
sive, the  pathway  being  prepared  by  a  more  or  less  gradual  dilatation 
of  the  ureter  or  ureters  by  backward  xjressure.  It  might  almost  be  as- 
serted that  chronic  ascending  pyelitis  is  a  late  stage  of,  often  a  sequel 
to,  most  chronic  diseases  of  the  urinary  tract,  and  that  its  grade  is  in 


CHIEF  URINARY  DISEASES   PRODUCING   PYURIA.  607 

direct  proportion  to  tlie  duration  and  severity  of  tlie  vesico-urethral 
obstruction. 

Especial  attention  may  be  directed  to  two  diseases  which  are  most 
prone  to  affect  the  ureters  although  no  previous  distention  of  their 
channels  have  occurred.  These  are  c,ystitis  in  the  female,  following 
pregnancy,  and  primary  tubercular  disease  of  the  bladder. 

Pyuria  of  Vesical  Origin. — All  the  diseases  of  the  bladder  provoke 
the  appearance  of  pus,  either  in  an  early  or  in  a  later  stage ;  the  char- 
acter of  the  discharge  is  of  no  diagnostic  value,  though  much  can  be 
gathered  concerning  the  grade  of  the  inflammation,  and  the  dejjth 
to  which  it  has  penetrated  the  vesical  wall,  from  its  aspect  and  smell. 
Thus,  very  slight  amounts  of  i)us  in  acid  urine,  with  vesical  symp- 
toms, denote  localized  surface  changes  such  as  are  seen  in  early  tuber- 
culosis, or  in  the  cystitis  of  the  female  bladder  of  uterine  or  ovarian 
origin.  The  thick,  roi)y  pus  which  is  alkaline,  and  ammoniacal  in 
smell,  denotes  a  more  chronic  form  in  which  there  is  some  general 
and  deeper  penetration,  and  some  constant  source  of  irritation,  such 
as  a  calculus  or  decomposing  residual  urine.  "When  the  entire  thick- 
ness of  the  wall  has  been  implicated  (parenchymatous  cystitis) ,  the 
feculent  odor  denotes  the  transmigration  of  micro-organisms  and 
their  products  from  the  adjoining  gut.  The  age  of  the  patient  in 
whose  urine  vesical  pus  appears  affords  some  clue  to  the  origin  of 
the  pus.  It  is  rare  in  childhood,  unless  stone  is  present.  Between 
puberty  and  adult  life,  if  gonorrhoea  is  excluded,  it  is  generally  due 
to  tubercular  affection.  Between  twenty  and  thirty  most  of  the  so- 
called  inflammations  of  the  bladder  are  really  cases  of  posterior  ure- 
thritis of  gonorrhoeal  origin  involving  the  bladder  neck.  In  women 
between  twenty  and  thirty-five  the  pressure  and  inflammatory  troubles 
of  pregnancy  account  for  many  of  the  inflammations  to  which  the 
female  bladder  is  liable,  and  the  obstinate  character  of  the  disorder 
would  be  incomprehensible  were  it  not  realized  that  the  original  focus 
of  the  inflammation  remains  unabated  in  the  shape  of  some  chronic 
uterine  mischief.  In  mid-adult  life  the  cystitis  of  stricture  and  some- 
times that  of  spinal  atonies  are  encountered,  but  usually  the  most 
fruitful  cause  of  pyuria  commencing  at  or  about  the  age  of  fifty,  is 
found  in  the  changes  to  which  the  prostate  is  liable,  and  in  the 
many  secondary  inflammatory  conditions  which  it  induces. 

Pyuria  of  Urethral  Origin. — In  the  strict  sense  of  the  term,  ure- 
thral pyuria  merely  relates  to-  inflammatory  conditions  arising  behind 
the  compressor  urethrge,  for  pus  arising  from  diseases  of  the  penile 
urethra  issues  independently  of  micturition,  since  there  is  no  muscle 
in  the  urethra  between  the  comx)ressor  and  the  meatus  to  check  the 
free   exit   of  the   discharge.     Inflammation   of  the  posterior  (deep) 


608  FENWICK — DISEASES  OF  THE  UKINE. 

uretlira  is  usually  accompanied  by  irritability  of  the  bladder  and 
usually  by  some  sense  of  obstruction  to  the  stream.  The  three-glass 
test  serves,  however,  to  divorce  it  from  an  inflammation  of  that 
viscus. 

Treatment  op  Pyueia. 

Stimson  wisely  draws  attention  to  the  necessity  of  preventing 
pyelitis,  and  this  is  possible  to  a  considerable  extent  in  those  classes 
which  furnish  the  largest  number  of  cases — the  calculous  and 
ascending  forms.  For  prevention  of  the  former  the  reader  is  re- 
ferred to  the  article  on  stone  in  the  kidney,  and  I  have  attempted,  both 
in  this  section  and  in  that  on  hsematuria,  to  emphasize  the  amount 
of  damage  surgery  can  do  to  the  renal  functions  by  rough  and  inju- 
dicious action  in  treating  diseases  of  the  lower  urinary  tract.  I  am 
con^dnced  that  much  of  the  destruction  caused  by  the  ascending  form 
of  pyelitis  might  be  prevented,  for  it  is  not  only  those  patients  that 
die  rapidly  from  renal  suppression  after  instrumental  interference, 
who  are  the  sole  victims.  Many  leave  our  care  with  more  or  less 
crippled  kidneys,  and  though  they  are  regarded  and  recorded  as 
cures,  3'et  some  intercurrent  disease  or  some  subsequent  chance  con- 
gestion accentuates,  or  renders  irreparable,  the  renal  damage  which 
might  in  the  first  instance  have  been  avoided.  The  subject  will  be 
attended  to  in  the  various  sections  on  treatment,  but,  as  a  general  rule, 
no  operation  on  the  lower  urinary  tract  should  be  undertaken  unless 
the  patient  has  rested  for  some  time  previously  in  bed,  or  unless  the 
urinary  passages  have  been  disinfected  as  far  as  possible  by  the-  inter- 
nal exhibition  of  drugs,  such  as  boric  acid  and  benzoate  of  soda,  salol, 
naphthol,  diuretin  or  what  appears  to  be  its  equivalent,  sodio-salicyl- 
ate  of  theobromine,  in  ten-grain  doses  every  four  hours  (Stimson) . 

The  treatment  of  pyuria  is  so  intimately  linked  with  its  causation 
that  those  forms  which  are  more  commonly  encountered  must  be 
considered  separately,  and  this  mainly  under  the  head  of  Instrumen- 
tal Interference.  For  there  are  few  cases  of  confirmed  pyuria,  if  we 
except  tuberculosis,  which  may  not  be  benefited  by  surgical  aid. 

General  Treatment. — If  the  pus  appears  as  the  result  of  a  simple 
catarrh,  it  will  probably  subside  after  rest  in  bed,  and  the  free  exhibi- 
tion of  bland  diluents,  to  which  some  form  of  alkali  is  added,  hot  fo- 
mentations being  applied  and  opium  given  if  necessary.  If  the  pus 
is  small  in  amount,  but  constant,  and  is  not  developed  during  some 
acute  infectious  fever,  it  may  be  subdued  by  boric  acid  and  sodium  ben- 
zoate, this  mixture  being  especially  useful  when  the  urine  shows 
phosphatic  tendencies.  The  chronic  pj^elitis  of  gouty  people  is 
greatly  benefited  by  a  course  of  Contrexeville  or  Wildungen  water. 


TEEATMENT  OF  PYURIA.  609 

Failing  this,  tlie  balsams  in  small  doses   are  valuable — santal  oil, 
copaiba  oil,  and  turpentine. 

To  subdue  tbe  pus  in  ordinary  pyelitis,  .nitro-muriatic  acid  and 
quinine ;  alum,  or  tannic  acid  in  two-grain  doses,  if  much,  mucus  is  pres- 
ent; iron  in  large  doses;*  acetate  of  lead,  three  grains,  cautiously  in- 
creased, three  times  a  day — are  strongly  recommended.  When  poly- 
uria in  pyelitis  is  marked,  Morris  recommends  half-drachm  doses 
of  liquid  extract  of  ergot.  If  the  urine  is  fetid,  creasote  may  be  tried 
(Dickinson) .  A  liberal  diet,  a  change  of  air,  preferably  to  the  sea, 
when  the  pus  is  of  pyelitic  origin  and  passed  in  large  quantities,  is 
often  of  the  greatest  value. 

Acute  Primary  Pyelitis  and  Pyelonephritis. — ^Little  can  be  done  by 
the  surgeon  in  acute  forms  of  primary  inflammation  of  the  kidneys 
and  pelvis,  for  usually  the  disease  is  bilateral,  and  the  changes  are 
too  extensive  and  too  rapid  to  be  amenable  to  operation. 

Chronic  Pyelitis  and  Pyelonephritis. — When  the  disease  is  unilat- 
eral and  a  fair  percentage  of  urea  is  found  in  the  urine,  demonstrat- 
ing the  working  power  of  the  other  kidney,  the  surgeon  may  interfere 
with  a  reasonable  chance  of  success.  In  calculous  pyelitis,  after  medi- 
cal treatment  has  been  fairly  tried,  no  time  should  be  lost  in  clearing 
out  the  pelvis  by  the  lumbar  route.  Each  year  adds  to  the  dangers  of 
pronounced  calculous  pyelitis  and  to  the  dif3&culty  of  removing  the 
calculus  without  damage  to  the  future  working  capacity  and  stress 
resistance  of  the  kidney.  Moreover  Turner's''^  post-mortem  statistics, 
which  represent  the  condition  of  calculous  kidneys  which  have  run 
their  course,  are  pregnant  with  the  lesson  of  early  interference.  Of 
forty-three  cases  of  renal  calculi  described  in  the  post-mortem  records 
of  St.  George's  Hospital  for  the  past  twenty-one  years,  pyonephrosis 
was  present  in  twelve  cases.  In  nine  the  ureter  was  completely 
blocked,  and  in  eight  of  these  the  obstruction  was  at  the  renal  end. 
With  regard  to  the  condition  of  the  unaffected  kidney  in  those  cases  in 
which  only  one  side  was  calculous,  it  was  granular  and  cystic  in  nine, 
lardaceous  in  two.  There  remained  only  eight  cases  in  which  the 
other  kidney  was  either  healthy  or  hypertrophied. 

•  Concerning  this  operation  only  the  following  remarks  need  be 
added :  When  the  calculous  pyelitis  has  been  in  existence  for  some 
time,  the  surroundings  of  the  kidney  will  be  found  very  densely 
matted  and  adherent,  and  in  some  cases  they  will  resemble  the  gelat- 
inous surroundings  of  advanced  tuberculosis  of  the  kidney.  Al- 
though the  stone  may  be  removed  a  permanent  sinus  may  be  left, 

*  It  must  be  remembered  that  small  doses  of  iron  not  inrrcquently  aggravate  a 
pyuria. 

Vol.  I.— 39 


610  FENWICK — DISEASES  OF  THE  UBINE, 

and  to  avoid  this  the  surgeon  must  decide  whetlier  nephrectomy  ought 
not  to  be  done,  the  stress  resistance  of  the  opposite  kidney  having 
been  previously  ascertained.  * 

In  calculous  pyonephrosis  the  operation,  consisting  merely  in 
clearing  away  the  calculi  and  washing  out  the  sac,  is  easy,  but  the  re- 
sulting shock  is  often  severe  and  this  apparently  in  proportion  to  the 
size  of  the  tumor.  In  some  instances  the  patient  has  died  suddenly 
a  few  hours  after  the  operation.  It  may  be  that  the  cardiac  muscle 
had  become  affected  by  absorption  from  the  puriform  sac,  for  shock 
does  not  follow  the  removal  of  large  amounts  of  urine  from  hydrone- 
phrotic  sacs.  When  perinephritis  has  ensued  on  perforating  pyelitis, 
it  will  be  better  in  most  cases  to  remove  the  kidney  at  the  same  time 
that  the  perinephritic  collection  is  evacuated ;  or,  if  the  sac  is  so  enor- 
mous that  the  kidney  has  been  pressed  out  of  reach,  then  nephrec- 
tomy had  better  be  postponed  for  a  week,  after  which  time  the  kidney 
will  have  regained  its  normal  position. 

Probably  Dickinson"  has  since  seen  fit  to  alter  the  following 
cautious  opinion  which  he  expressed  in  1885 :  "  Where  pyelitis  is  con- 
joined with  obstruction  of  the  outlet  and  has  led  to  so  much  accumu- 
lation of  pus  as  to  cause  bulging  in  the  loin,  the  question  of  puncture 
or  incision  may  be  entertained,  but  I  think  it  is  generally  safest  to 
wait  until  the  matter  has  worked  through  its  renal  investment  and 
presented  in  the  back,  and  even  then  until  it  is  nearly  subcuta- 
neous, rather  than  to  seek  for  it  deeply." 

Primary  Tubercular  Pyelitis. — The  only  reasonable  chance  of  suc- 
cess in  this  disease  is  the  early  removal  of  the  diseased  kidney  and  as 
much  of  the  ureter  as  is  possible.  Nephrotomy  has  not  proved  of 
much  assistance,  although  the  incision  through  the  capsule  has  re- 
lieved the  intense  pain  that  is  often  suffered  in  the  renal  region. 
Also  by  diverting  the  tide  of  acrid  pyelitic  urine  through  the  loin  the 
irritability  and  frequency  of  micturition  are  allayed.  Merely  scoop- 
ing out  scrofulous  deposits  and  stufiing  the  cavity  of  the  abscess  with 
iodoform  gauze  is  rarely  curative,  for  many  other  deposits  in  the 
parenchyma  usually  coexist,  and  these,  if  they  are  overlooked,  be- 
come infected  and  the  temperature  does  not  drop.  Besides,  the  ure- 
ter is  imperfectly  drained,  and  the  disease  progresses  more  rapidly 
because  septic  changes  have  been  set  in  action  by  the  exploration. 

Ascending  Pyelitis. — The  great  secret  of  the  prevention  of  ascending 
pyelitis  rests  in  asepticism,  extreme  gentleness,  and  free  bladder 
drainage.     This  is  especially  the  case  when  the  deep  urethra  is  resent- 

*  I  hold  very  strongly  that  no  interference  with  the  kidney  should  be  undertaken 
unless  permission  has  been  given,  and  preparations  have  been  made,  to  remove  the 
organ  if  it  be  found  wise  to  do  so  after  examination. 


TREATMENT  OP  PYURIA.  611 

ful,  as  in  the  case  of  gouty  and  onanitic  prostates.  Probably  tlie  reason 
why  Frere  Come  was  so  successful  in  suprapubic  cystotomy  was  be- 
cause of  the  perineal  drainage  he  invariably  employed.  Much  of  the 
ascending  pyelitis  now  grafted  by  surgery  on  a  diseased  and  dilated 
ureter  might  probably  be  avoided  by  bladder  drainage  through  a 
small  perineal  wound.  This  is  especially  indicated  in  calculous  af- 
fections of  the  bladder  in  old  age,  the  stone  being  the  result  and  not 
the  cause  of  the  chronic  cystitis.  Ascending  pyelitis  is  often  mark- 
edly and  distinctly  improved  by  bladder  drainage,  a  subject  to  which 
Mr.  Harrison  and  Professor  Guyon^"*  have  lately  drawn  special  at- 
tention. The  latter  authority,  in  a  clinical  lecture  based  upon  two 
cases  of  women  with  simultaneous  pain  in  the  bladder  and  kidneys, 
has  emphasized  the  value  of  drainage.  One  patient  passed  urine  full 
of  pus,  the  kidneys  were  large  and  painful,  and  she  suffered  from 
agonizing  attacks  of  vesical  spasm.  There  was  also  feverishness  with 
dry  tongue  and  dyspepsia.  M.  Guyon  concluded  that  the  origin  of 
the  trovible  lay  in  the  bladder,  and  that  it  was  not  advisable  to  operate 
on  the  kidney  at  once.  The  bladder  was  therefore  laid  open  from 
the  vagina,  and  kept  open.  The  vesical  pains  at  once  ceased  and 
the  spasms  never  returned.  The  condition  of  the  kidneys  slowly 
improved,  and  the  pain  disappeared ;  they  ultimately  diminished  in 
size  and  ceased  to  be  palpable  on  manual  exploration. 

M.  Guyon  bases  treatment  of  this  kind  on  careful  examination 
of  the  bladder.  When,  as  in  this  case,  the  sound  causes  severe 
pain  when  it  touches  the  mucous  membrane,  when  the  bladder  is  ten- 
der on  pressure  of  the  hand  over  the  pubes,  or  of  the  forefinger 
against  the  anterior  vaginal  wall,  the  primary  lesion  will  be  in  the 
bladder,  and  the  renal  swelling  and  pain  will  be  secondary.  Let  the 
bladder  rest  then,  and  the  kidney  will  empty  itself,  and  this  will  cause 
subsidence  of  the  pathological  changes  in  the  renal  pelvis  and  glan- 
dular tissue.  All  such  cases  do  not  demand  such  active  treatment  as 
cystotomy.  Simple  medical  treatment  of  cystitis,  rest  and  weak  anti- 
septic injections  may  be  sufficient  if  taken  in  time.  On  the  other 
hand,  Bozeman's  treatment  of  pyonephrosis  by  the  establishment 
of  a  vesico-vaginal  fistula,  and  subsequent  catheterization  of  the 
ureters,  cures  the  renal  complication  on  the  same  principle,  but  the 
practice  is  only  to  be  undertaken  by  experts. 

M.  Guyon's  second  patient  was  in  an  earlier  stage  of  treatment 
when  his  lecture  was  delivered,  but  the  vesical  pain,  fever,  and  dry 
tongue  had  disappeared.  In  a  neighboring  ward  lay  a  man  who  had 
entered  with  retention  and  infiltration  of  urine  from  giving  way  of 
the  urethra ;  at  the  same  time  a  large  pyonephrosis  of  the  right  kid- 
ney was  detected.     The  infiltration  and  retention  were  treated  in  the 


612  FENWICK — DISEASES  OF  THE  UKINE. 

usual  maimer.  Within  two  months  all  tlie  physical  signs  of  pyone- 
phrosis had  completely  disappeared.  "  To  run  to  the  assistance  of  the 
kidneys  by  methodical  treatment  of  the  lower  part  of  the  urinary 
tract  should  be  a  fundamental  law  of  surgery." 

But  drainage  does  not  always  succeed.  Thus,  in  one  case  of 
severe  unilateral  pyelitis  the  result  of  backward  pressure  from  an 
enlarged  median  prostatic  lobe,  I  first  removed  the  lobe  suprapu- 
bically  and  the  bladder  was  then  drained  for  more  than  two  months, 
but  the  formation  of  pus  did  not  subside.  After  a  year,  although 
the  stream  was  full  and  free  and  the  residual  urine  only  amounted  to 
an  ounce,  the  amount  of  pyelitic  pus  was  still  one-third.  I  there- 
fore incised  the  kidney  and  evacuated  an  abscess  from  the  deep 
part  of  the  cortex  and  drained  the  pelvis.  The  urine  at  once  be- 
came crystal  clear  and  remained  so  for  some  days,  until  the  renal 
drain  was  left  out,  after  which  it  relapsed,  but  never  reached  again 
the  same  severe  grade.  Prolonged  renal  drainage  in  these  cases 
does  not  mean  for  a  few  weeks,  it  is  a  question  of  months,  and  the 
struggle  lies  in  preventing  the  wound  in  the  integuments  from  clos- 
ing. One  mistake  will  occasionally  be  made,  namely,  that  of  pre- 
serving hopelessly  damaged  kidneys.  The  drain- wound  heals  and 
the  abscess  recurs.  This  may  be  indefinitely  repeated  until  the 
patient  suddenly  develops  acute  septic  infection. 

Vesical  Pyuria. — The  treatment  of  suppuration  from  the  bladder 
consists  in  first  removing  the  cause  of  any  permanent  irritant,  such 
as  stone,  stricture,  or  enlargement  of  the  prostate,  which  may  be  dis- 
covered, and  for  the  management  of  which  the  reader  is  referred  to 
the  article  on  such  diseases.  Should  any  such  irritant  be  absent,, 
the  various  methods  of  treating  cystitis  must  be  employed. 

The  treatment  of  the  acute  form  must  be  carried  out  regardless  of 
the  cause,  for  in  all  operative  work  about  the  bladder,  inflammation 
must  be  first  subdued  before  any  instrumental  interference  is  com- 
menced. In  the  acute  stage  there  are  three  powerful  agents  in  reduc- 
ing the  severity  of  the  attack,  viz.,  1.  Rest  in  bed  with  elevated  hips; 
2.  Free  imbibition  of  diluents;  3.  Anodynes  administered  by  the 
bowel.  The  elevation  of  the  hijjs  withdraws  from  the  bladder  the 
pressure  of  the  intestines.  The  diluents  render  the  urine  copious  and 
as  non-irritating  as  possible.  Those  which  are  the  most  reliable  are 
"teas,"  made  of  linseed,  buchu,  or  triticum  repens.  Those  who  can 
obtain  it  fresh  and  good  can  rely  upon  the  liquid  extract  of  Col- 
linsonia  Canadensis  (ttixx.),  or  the  extractum  stigmatum  maidis. 
They  are  often  invaluable.  Taken  separately  or  in  combination  with 
these  should  be  a  suJBficient  amount  of  alkali  to  render  the  urine  less 
irritating.     Citrate  of  potash  or  liquor  potasses  are  the  most  useful. 


TEEATMENT  OP  PYUEIA.  613 

Anodynes  act  best  by  the  bowel.  A  suppository  of  watery  ex- 
tract of  opium,  gr.  ss.,  or  of  morphine,  gr.  ^-^,  combined  with  extract 
of  belladonna,  gr.  ss-i.,  is  the  most  serviceable.  In  addition  to 
these  remedies  a  hot  hip-bath  from  100°  to  105°  should  be  given  for  a 
quarter  of  an  hour  two  or  three  times  daily,  and  hot  applications  made 
to  the  perineum  and  pubes  either  by  Leiter's  coils,  hot  flannels, 
spongio-piline,  or  poultices  frequently  changed.  Hot  rectal  enemata 
twice  or  thrice  a  day  are  most  soothing,  besides  being  of  value  in 
keeping  the  lower  bowel  clear.  Laxatives  and  a  fluid  diet  complete 
this  plan  of  treatment.  In  subacute  cystitis  the  balsams  are  of 
use — sandalwood,  copaiba,  turpentine.  In  chronic  cases,  if  the 
source  of  the  trouble  has  been  removed,  vesical  irrigation  must  be 
employed,  but  with  this  reservation,  that  if  signs  of  tubercular  deposit 
in  any  part  of  the  body  are  discovered  the  use  of  the  catheter  must 
be  sedulously  avoided.  The  injections  which  will  be  found  the  most 
serviceable  are  boro-glyceride  solution;  iodoform  emulsion  (five 
grains  suspended  in  an  ounce  of  mucilage  and  water),  left  in  the 
bladder  after  it  has  been  thoroughly  cleansed  by  weak  solution  of 
permanganate  of  potash ;  salicylic  acid  (one-half  per  cent,  cautiously 
increased) ,  and  finally  a  solution  of  mercury  perchloride  of  the  strength 
of  1  in  10,000. 

The  cure  of  cystic  pyuria  in  the  female  depends  greatly  on  the 
cure  of  the  metritis,  perimetritis,  ovaritis,  or  uterine  displacement 
which  frequently  accompanies  and  often  has  been  the  cause  of  the  com- 
plaint. Much  stress,  and  deservedly,  has  been  placed  upon  resting 
the  female  bladder  in  the  aggravated  forms  of  cystitis  when  drugs 
and  injections  have  failed.  This  is  accomplished  by  dilating  the 
urethra  or  by  making  a  buttonhole  fistula  in  the  base  through  the 
vaginal  roof.  Dr.  More  Madden  has  found  that  marked  relief  is 
obtained  by  forcible  dilatation  of  the  urethra  and  the  induction  by 
this  means  of  temporary  incontinence  of  urine,  accompanied  by  the  free 
application  of  glycerin  of  carbolic  acid  to  the  mucous  membrane. 
Two  or  three  applications  at  intervals  of  ten  days  may  be  required. 

Urethral  Pyuria. — The  treatment  mainly  consists  in  quieting  the 
cystitis  of  the  neck  of  the  bladder  which  coexists  to  a  greater  or  les- 
ser extent  in  every  case ;  in  removing  any  permanent  cause  of  ob- 
struction, such  as  stricture,  or  any  direct  irritation  such  as  a  prostatic 
calculus.  Subsequent  injections  in  the  deep  urethra  may  be  made 
by  means  of  either  Guyon's  or  Ultzmann's  syringe.  With  the  for- 
mer, five  or  ten  drops  of  a  solution  of  nitrate  of  silver  in  strength 
varying  from  five  to  twenty  grains  to  the  ounce  are  thrown  directly 
into  the  membrano-prostatic  urethra.  Ultzmann  recommends  most 
strongly  the  irrigation  of  the  neck  of  the  bladder  as  well,  and  this 


614  FENWICK — DISEASES  OF  THE  URINE. 

is  carried  out  by  throwing  into  tlie  deep  urethra  eight  ounces  of  the 
nitrate  of  silver  solution  of  a  strength  of  one  grain  to  eight  ounces. 
This  enters  the  bladder  slowly,  and  after  being  held  for  a  few  minutes 
is  expelled  by  the  patient  voluntarily. 

Peognosis  oe  Pyuria, 

As  some  stress  has  been  laid  upon  the  necessity  of  operative  in- 
terference in  the  treatment  of  obstinate  and  aggravated  pyuria,  it  is  but 
right  that  the  prognosis  of  the  untreated  forms  should  be  touched 
upon.  There  is  no  doubt  but  that  cases  of  pyelitis  have  resulted 
in  a  spontaneous  cure.  Moreover,  on  the  post-mortem  tables  small 
atrophic  kidneys  containing  a  cheesy  material  or  the  dried  chalky  re- 
mains of  pus,  or  a  large  urinary  calculus,  have  been  frequently  dis- 
covered, and  the  corresponding  ureters  have  been  found  thickened 
and  contracted.  This  fortunate  termination  cannot,  however,  be  reck- 
oned upon,  and  it  is  noteworthy  that  many  of  these  cases  had  had 
no  history  of  symptoms  referable  to  the  disease.  Hence  probably  no 
accentuation  of  their  condition,  by  the  well-meant  but  mischievous 
exploration  of  the  bladder,  had  been  undertaken.  The  gravity  of  pye- 
litis is  in  direct  relation  to  its  cause.  I  believe  I  have  seen  undoubted 
cases  of  tubercular  pyelitis  recover,  temporarily  at  least,  under  favor- 
able dietetic  and  hygienic  conditions,  and  I  have  met  with  unquestion- 
able cases  of  vesical  and  prostatic  tuberculosis  which  have  been  in  abey- 
ance for  as  many  as  twenty  years.  This,  however,  is  the  exception, 
and  most  cases  of  this  kind  end  fatally.  The  calculous  form  of  pye- 
litis without  pyonephrosis  is  perhax)s  the  most  favorable  disease  of 
all.  As  a  rule  definite  pyonephrotic  tumors,  unless  relieved  by  art  or 
unless  they  discharge  themselves  through  the  loin,  are  undoubtedly 
fatal  in  the  end.  Of  the  ascending  chronic  forms  of  pyelitis,  that 
which  follows  pregnancy  may  be  considered  as  being  the  most  favor- 
able. Probably  the  great  improvement  which  now  obtains  in  the  treat- 
ment of  vesical  stone,  enlarged  prostate,  and  stricture,  will  improve 
the  prognosis  of  pyelitic  complications  of  these  disorders.  These 
have  hitherto  being  considered  as  extremely  grave.  One  remark  only 
need  be  made :  A  patient  with  a  pyelitis  or  a  slight  pyonephrosis 
may  continue  well,  or  apparently  well,  for  years.  Suddenly,  without 
any  previous  warning  or  appreciable  cause,  a  change  for  the  worse 
occurs.  Rigors,  high  temperature,  vomiting,  thirst,  extreme  pain  in 
the  side  or  back,  and  prostration,  mark  the  sudden  general  absorp- 
tion of  pyogenic  poisons  from  a  sac  which  has  for  long  intervals  been 
quiescent.  Often  the  patient  is  beyond  hope  even  when  an  operation 
is  immediately  undertaken. 


ACCIDENTAL  ALBUMINURIA.  615 


ACCIDENTAL  ALBUMINURIA. 

It  lias  long  been  accepted  that  tlie  mere  presence  of  albumin  in 
the  urine  in  small  quantities  does  not  necessarily  indicate  the  presence 
of  organic  disease  of  the  kidneys.  When  traces  of  albumin  are 
present  and  no  organic  disease  of  the  kidney  can  be  discovered,  the 
symptom  is  termed  functional  albuminuria.  This  subject  still  re- 
quires elucidation,  although  the  literature  is  copious  and  recent. 
Senator,  Leube,  Posner,  and  others  hold  that  traces  of  albumin  may 
be  found  in  the  urine  of  healthy  people  (physiological  albuminuria) . 

Many  of  the  observations  recorded,  however,  lack  the  imprint 
of  accurate  research  for  determining  the  presence  of  serum  al- 
bumin as  distinct  from  that  which  is  said  to  characterize  cardiac 
and  amyloid  kidney  (Semmola),  osteomalacia,  and  other  diseases. 
There  is  no  doubt,  however,  that  some  of  the  cases  which  are  con- 
sidered to  be  albuminuric  are  examples  of  mistaken  diagnosis,  due  to 
inaccurate  examination.  Thus  Malfatti  ^^  mistook  mucin  for  serum 
albumin.  In  some,  traces  of  blood  or  pus  have  been  overlooked,  in 
others  an  obstruction  to  the  free  outlet  of  urine  from  the  ureter  or 
bladder  has  remained  undiscovered,  and  the  albumin  detected  in  the 
urine  is  serum  due  to  strangury  or  spasm.  Lastly  some  of  the 
young  men,  in  whom  a  diagnosis  of  albuminuria  is  made,  are  passing 
seminal  or  prostatic  fluid  in  their  urine,  and  in  such  cases  it  is  well 
known  that  a  trace  of  albumin  may  be  found.  In  this  article  we 
shall  treat  of  those  cases  in  which  albumin  emanating  from  an  extra- 
renal source  becomes  mixed  with  the  urine,  a  condition  known  as 
accidental  albuminuria. 

Extra-Renal  Albuminuria,  or  accidental  albuminuria,  is  due  to  the 
presence  of  (a)  pus,  (5)  blood,  (c)  serum,  {d)  chyle,  (e)  semen. 

a.  Pus. — The  urine  of  gouty  people  not  infrequently  contains  a 
slight  admixture  of  pus  arising  from  a  mild  catarrh  due  to  the  irrita- 
tion, direct  or  indirect,  of  uric  acid.  The  pus  may  come  from  &n.j 
part  of  the  collecting  or  conducting  passages,  and  no  symptoms  are 
Xjresent  to  mark  its  origin  or  cause.  Dietetic  irregularities  or  exposure 
to  cold,  in  feeble  and  delicate  persons,  especially  in  the  middle-aged 
and  elderly,  says  Kalfe,  will  often  induce  a  catarrh  of  the  mucous 
membrane,  of  sufficient  intensity  to  lead  to  the  formation  of  pus 
corpuscles.  Virchow  has  recentl3^  related  how  in  his  own  case, 
during  an  attack  of  gout,  his  urine  became  albuminous  and  on  exami- 
nation was  found  to  contain  i)us,  with  an  abundant  deposit  of  uric- 
acid  crystals.'"' 

Perhai)S,  however,  the  larger  number  of  mistakes  are  made  in  deal- 


616  FENWICK — DISEASES  OF  THE   UKIKE. 

ing  with  patients  wlio  are  suffering  from  a  symptomless  deep  gleet 
and  its  effects. 

The  f  olloAving  is  an  excellent  example : 

An  officer  of  the  English  army  was  offered  an  important  African 
governorship,  but  found  himself  debarred  from  accepting  it  by  a 
medical  report  that  he  was  suffering  from  albuminuria.  He  had 
seen  active  and  arduous  service  in  Afghanistan,  and  it  was  supposed 
that  the  cold  to  which  he  had  been  exposed  had  induced  nephritis. 
On  examination  I  found  a  simple  valve  nearly  occluding  the  deep 
urethra,  and  his  urine  contained  a  microscopic  amount  of  pus. 
Dilatation  of  the  stricture,  and  a  few  applications  of  nitrate  of  silver 
to  the  serum-sweating  surface  behind  it,  was  all  that  was  required 
to  remove  the  fancied  albuminuria,  and  to  procure  his  appointment. 

I  could  record  several  other  and  similar  examples,  but  the  fol- 
lowing, which  illustrates  an  analogous  condition  of  the  ureter,  is  too 
emphatic  to  be  omitted : 

A  patient  aged  fifty-six  was  brought  to  me  to  determine  the  cause 
of  an  intermittent  hsematuria,  which  had  been  noticed  for  some  years. 
A  very  distinguished  physician  had  examined  the  patient  several 
times  before,  and  had  analyzed  the  urine.  More  than  a  marked 
trace  of  albumin  had  been  found  in  clear  urine,  which  was  of  low 
specific  gravity,  and  casts  had  also  been  seen.  A  diagnosis  of 
chronic  Bright' s  disease  had  been,  therefore,  supplied  to  the  practi- 
tioner in  charge  of  the  case.  The  cystoscope  revealed  a  tough  fibro- 
papilloma,  spreading  around  and  partly  occluding  the  left  ureteral 
orifice,  the  ejected  contents  of  which  tube  were  murky  and  contained 
pus  and  flakes.  Obviously  the  throttling  of  the  ureteral  orifice  had 
induced  back-pressure  changes  and  mild  ascending  pyelitis.  Urine 
from  the  other  kidney  showed  an  ordinary  specific  gravity  (1.025) ;  it 
was  acid,  clear,  and  contained  2.5  per  cent,  of  urea.  Thus  the  dis- 
charge from  the  pelvis  of  one  ureter  was  incautiously  inferred  to 
represent  the  secretions  from  both  kidneys. 

6.  Blood. — A  small  quantity,  even  a  microscopic  trace,  means  a 
corresponding  amount  of  serum  albumin.  It  is  likely  that  some  at 
least  of  those  cases,  diagnosed  to  have  albumin  in  the  urine  from  ex- 
ertion, may  have  had  latent  renal  calculus  or  some  other  cause  for  the 
.  appearance  of  a  microscopic  quantity  of  blood  which  would  show,  on 
testing,  a  trace  of  albumin.  It  is,  I  believe,  especially  in  the  latent 
periods  of  villous  papilloma  or  other  forms  of  vesical  growth  that 
serum  albumin  and  small  quantities  of  blood  appear.  This  often 
happens  before  the  attack  of  hsematuria  which  first  draws  attention 
to  the  urinary  tract.  I  have  known  several  patients,  from  whom  I 
have  subsequently  removed  villous  papillomata,  to  present  themselves 
with  a  history  that,  in  the  earlier  stages  of  the  papilloma,  a  diagnosis 
of  Bright' s  disease  had  been  made. 


ACCIDENTAL  ALBUMINURIA.  617 

The  highest  accentuation  of  this  condition  is  found  in  the  symptom 
known  as  "fibrinuria  of  Ultzmann,"  in  which  the  urine  gelatinizes 
after  being  passed.  It  is  only  seen  in  rare  cases  of  villous  papilloma, 
and  it  is  due  to  the  straining  of  the  serum  through  the  slender  vessels 
of  the  fragile  growth. 

c.  Serum  Leakage. — The  albuminuria  of  spasm  or  strangury  is 
on  a  par  with  the  preceding,  although  the  character  of  the  surface 
from  which  the  albumin  leaks  is  different.  Usually  the  surface 
epithelium  has  been  shed  in  various  parts  of  the  bladder,  under  the 
influence  of  a  chronic  inflammation,  and  the  spasm  set  up  by  some 
form  of  obstruction,  such  as  enlarged  prostate,  stone,  or  stricture, 
strains  through  the  weakened  wall  a  variable  amount  of  serum.  I 
believe  that  many  patients  are  denied  the  benefit  of  operation  by  the 
discovery  of  more  albumin  in  the  urine  than  can  be  accounted  for  by 
the  pus  present.  In  the  case  of  one  patient  on  whom  several  attempts 
had  been  made  to  remove  an  enlarged  median  lobe  by  the  perineal 
route,  the  surgeon  became  alarmed  by  the  appearance  of  a  c^uantity 
of  albumin  in  the  urine  and  refrained  from  operation.  The  patient 
came  ultimately  under  my  care.  Not  only  were  the  kidneys  intact, 
but  he  bore  a  very  profuse  hemorrhage  from  suprapubic  prostatec- 
tomy, without  any  depression,  and  completely  regained  his  health 
and  bladder  power,  the  albumin  disappearing  directly  the  vesical 
straining  induced  by  the  prostatic  obstacle  had  been  relieved.  Serum 
leakage  is  also  found  in  tubercular  ulceration  of  the  bladder,  where 
there  is  spasm  of  the  detrusor  muscle.  Perhaps  this  false  albu- 
minuria occurs  more  often  in  vesical  calculus  than  is  usually  believed. 
In  one  instance  I  refused  for  some  time  to  operate  for  stone  on  ac- 
count of  the  decided  amount  of  albumin  in  the  urine,  and  yet  the 
patient  bore  a  suprapubic  lithotomy  for  the  removal  of  a  three-ounce 
calculus  without  difliculty,  and  the  water  cleared  subsequently. 

d.  Chyle. — The  admixture  of  chyle  also  with  the  urine  in 
chyluria  causes  the  secretion  to  be  albuminous.  See  section  on 
Chyluria. 

e.  Seminal  and  Vesicular  False  Albuminuria. — It  is  stated  that  al- 
bumin is  found  in  young  males  who  are  passing  seminal  or  prostatic 
fluid.  In  these  the  microscope  will  reveal  the  characteristic  appear- 
ances of  the  fluid,  and  if  this  can  be  established  it  is  a  significant 
fact,  for  albumin  is  often  found  in  boys  attending  large  public  schools 
where  the  tendency  to  onanism  is  great. 

To  avoid  the  mistake  of  diagnosing  accidental  as  renal  albuminu- 
ria it  is  but  necessary  to  filter  the  urine,  examine  more  carefully  with 
the  microscope,  and  take  the  percentage  of  urea. 


618  FENWICK — DISEASES  OP  THE  UEINE. 


CYSTINURIA. 

The  passage  of  the  crystalline  body,  cystine  (cystic  oxide) ,  in  the 
urine  constitutes  the  symptom  known  as  cystinuria.  Cystinuria  is 
rarely  encountered,  only  about  seventy-five  cases  being  recorded  in 
the  literature ;  its  chief  clinical  interest  centres  in  the  formation  of 
cystine  gravel  or  stone. 

Cystine,  which  is  one  of  the  rarer  crystalline  urinary  deposits,  was 
discovered  by  Wollaston  in  1805,  in  a  calculus  composed  chiefly  of 
this  substance.  It  has  the  empirical  formula  CgHj^NoS^O^,  and  the 
researches  of  Baumann  leave  no  doubt  that  cystine  is  a  dithio- 
amido-ethjdidene-lactic  acid,  which  may  be  represented  by  the  sub- 
joined formula  (Gamgee) : 

o  /C  (CH3)  fNH„)  COOH 
.  ^\C  (CH3)  (NHJ  COOH 
It  occurs  in  normal  urine  in  minute  quantities  and  when  in  excess  it  is 
precipitated  in  the  form  of  a  whitish  or  pale  fawn-colored  deposit, 
very  similar  in  appearance  to  the  pale  urate  of  ammonia.  Micro- 
scopically this  precipitate  is  composed  of  six-sided  tablets  which  are 
very  characteristic.  These  plates  are  instantly  dissolved  by  the 
addition  of  ammonia,  but  crystallize  out  again  without  change  of 
form  as  the  ammonia  evaporates.  Cystine  is  soluble  in  ammonia  and 
the  mineral  acids,  but  not  in  acetic  or  tartaric  acid ;  it  is  insoluble  in 
carbonate  of  ammoAa,  water,  and  alcohol.  Heated  on  platinum  foil, 
the  fumes  are  thick  and  white,  and  resemble  garlic  in  smeU.  Cystine 
contains  no  less  than  25.5  per  cent,  of  sulphur. 

The  Chaeacter  op  Urine  Containing  Cystine. 

The  urine  of  a  cystinuric  patient  is  usually  murky  when  passed, 
and  is  faintly  acid  or  neutral.  It  has  a  yellow-green  color,  "  honey 
yellow,"  and  is  said  to  exhale  an  odor,  when  fresh,  resembling  sweet- 
briar  or  sweet  orris  root,  but  it  rapidly  fouls  from  decomposition, 
and  sulphuretted  hydrogen  is  evolved,  a  greasy-looking  scum  form- 
ing on  the  surface.  The  carbonate  of  ammonia  formed  by  the  de- 
composition of  the  urea  throws  down  a  bulky  deposit  of  cystine. 
Golding  Bird  noticed  that  the  urine  changes  in  decomposition  from 
yellow  to  green,  and  in  one  case  which  he  records  it  turned  to  a  bright 
apple-green.  It  is  stated  by  Niemann  that  urine  containing  cystine 
is  deficient  in  uric  acid,  and  Golding  Bird  asserts  that  urea  is  only 
present  in  very  small  quantities. 

Tests. — The  hexagonal  plate-like  crystals  are  characteristic,  and 


CY8TINURIA. 


619 


the  surest  test  for  cystine  is  recrystallization  after  the  crystals 
have  been  dissolved  in  ammonia.  The  precipitate  from  cystinuric 
urine  dissolves  in  potassic  hydrate,  and  if  a  solution  of  acetate  of 
lead  be  added  and  the  mixture  boiled,  the  black  precipitate  of  lead 
sulphate  will  result  (Liebig) .  But  all  sulphuretted  animal  matters 
similarly  treated  yield  black  precipitates ;  hence  this  test  is  useless 
if  any  portion  of  albuminous  substances  or  bile  be  mixed,  with  the 
deposit  (Bird). 

Roberts  says  that  the  ammoniacal  solution  of  cystine  generally 
deposits  hexagonal  plates  or  these  mixed  with  a  few  prisms  (vide  Fig. 
67) .  "  Sometimes,  how- 
ever, the  prisms  are  more 
abundant  than  the  plates. 
The  prisms  either  lie  singly 
or  form  stars.  They  re- 
fract light  strongly,  and 
the  facets  which  lie  slant- 
ingly out  of  the  direct  line 
of  vision  appear  j)erfectly 
black,  contrasting  with  the 
brilliant  lustrous  white  of 
the  planes  through  which 
the  light  passes  vertically. 
This  gives  a  peculiar 
striped  appearance  to  the 
prisms,  and  causes  them 
to  appear  deceptively  six- 
sided.  The  hexagonal  tab- 
lets have  an  iridescent  mother-of-pearl  lustre,  their  surfaces  being 
often  beautifully  chased  by  lines  of  secondary  crystallization;  they 
also  form  thick  rosettes  of  great  brilliancy." 

Calculous  Formation. — Cystine  calculi,  which  cannot  be  said  to 
possess  any  characteristic  size  or  shape,  are  probably  formed  in  the 
kidney  pelvis,  and  descend  into  the  bladder.  They  are  usually 
smooth  on  the  surface.  They  crush  or  break  without  crispness,  and 
feel  waxy  in  the  grasp  of  the  lithotrite,  proving  soft  and  compres- 
sible, and  the  fragments  are  evacuated  by  suction  often  with  difficulty. 
The  fractured  surface  is  crystalline  in  appearance  and  of  lemon- 
yellow  color.  The  calculi  are  usually  without  lamination.  Phos- 
X)hates  may  form  the  coating  of  the  calculus  and  uric  acid  the  nucleus. 
When  slightly  burnt  in  a  candle  flame  or  rubbed  on  a  handkerchief 
they  emit  an  odor  of  garlic. 

When  the  calculi  are  fresh  their  color  is  of  a  pale  yellowish- 


FiG.  67.— Cystine.    Hexagonal  tablets  and  prisms. 
(Roberts.) 


620  FENWICK — ^DISEASES  OF  THE  TJEINE. 

brown;  they  undergo,  however,  a  remarkable  ciiange  in  course  of 
time,  turning  slowly  from  brown  to  gray  or  green.  Thus  the  calculus 
described  by  Dr.  Marcet  in  1817  was  brown ;  now  it  exhibits  a  rich 
bluish-green  color.  This  alteration  is  considered  by  some  to  be  due 
to  the  changes  produced  by  the  sulphur.  A  similar  change  of  color 
has  been  observed  by  Dr.  Peter  in  two  cystine  calculi  preserved  in 
the  Transylvania  medical  museum ;  the  change  commenced  on  that 
side  of  the  concretion  which  was  exposed  to  the  light.    ■ 

Causation. 

The  causation  of  cystinuria  is  still  conjectural.  From  the  fact 
that  cystine  contains  sulphur  and  that  it  is  very  similar  in  its  com- 
position to  taurin  (Eoberts) ,  it  has  been  considered  that  the  symptom 
is  a  sign  of  hepatic  derangement,  and  Prout,  remarking  "  the  peculiar 
tallowy  and  waxy  character  of  the  complexion,"  so  frequently  noticed 
in  these  cases,  and  finding  fatty  matter  in  the  urine,  suggested  it  was 
the  outcome  of  fatty  liver.  Clinically  it  has  been  found  often  to 
coexist  with  disorders  of  the  hepatic  functions.  Thus  it  has  been  found 
in  the  liver  of  typhoid  patients,  and  is  sometimes  associated  with 
jaundice  and  other  symptoms  of  hepatic  derangement.  Virchow 
and  Scherer  have  detected  cystine  in  diseased  livers. 

Dr.  Dickinson  mentions  the  case  of  a  doctor,  who  had  habitually 
passed  cystine  crystals  in  the  urine.  The  patient,  when  Dr.  Dickinson 
saw  him,  had  extreme  ascites  with  evidence  of  obstruction  of  the 
portal  vein,  which  his  eventual  recovery  indicated  as  thrombotic. 
He  had  frequent  bilious  attacks.  A  second  attack  apparently  of 
portal  thrombosis,  more  severe  than  the  first  and  attended  with 
hsematemesis  x^rofuse  enough  to  endanger  life,  occurred  twenty-four 
years  after  the  commencement  of  cjstinuria.  During  convalescence 
the  cystine  was  observed  to  be  unusually  abundant.  It  was  noted  that 
bile  was  almost  absent  from  the  stools,  the  previous  inactivity  of  the 
liver  having  been  aggravated  apparently  by  the  sea  air.  No  hereditary 
proclivity  had  been  traced  in  this  case. 

Dr.  Ealfe  took  the  following  view  in  1885 :  "  Cystine  is  formed 
directly  from  taurin,  in  a  manner  perhaps  analogous  to  the  forma- 
tion of  indigo  from  indol.  The  observations  of  Naunyn  and  Dragen- 
dorff  have  shown  that  normal  urine  contains  traces  of  bile  acids,  of 
which  glycocholic  acid  is  the  chief,  so  that  it  is  probable  that  some 
portion  of  the  taurocholic  acid  is  oxidized,  and  furnishes  the  partially 
oxidized  sulphur  product,  which  in  minute  quantities  is  always  m 
normal  urine.  Moreover,  Dr.  Oliver  has  recently  shown,  by  means 
of  Ms  peptone  test,  that  the  bile  acids  are  often  enormously  increased 


OYSTINURIA.  621 

in  the  urine  in  many  morbid  conditions,  especially  those  connected 
with  functional  derangements  of  the  liver  and  anaemia  {Lancet,  April 
and  May,  1885) .  It  may  be,  therefore,  that  under  certain  conditions 
the  quantity  of  taurin  eliminated  by  the  kidney  is  increased,  or 
its  excretion  checked,  while  the  transformation  into  unoxidized 
sulphur  is  incompletely  carried  out,  so  the  intermediate  product 
cystine  is  the  result." 

Up  to  within  a  short  time  these  various  theories  were  accepted, 
but  the  recent  researches  into  the  intestinal  ptomaines  have  thrown  an 
unexpected  and  startling  light  upon  the  production  of  cystinuria,  and 
although  at  present  the  views  put  forward  cannot  be  accepted  in  their 
entirety,  sufficient  evidence  is  forthcoming  to  establish  some  casual 
relation  between  cystinuria  and  a  form  of  intestinal  mycosis  of  an 
infecting  type. 

Thus  the  researches  of  Stadthagen  and  Brieger,  v.  Udransky, 
and  Baumann  have  shown  that  cystinuric  urines  contain  diamines, 
and  in  particular  putrescin,  cadaverin,  and  a  diamine  which  is 
isomeric  with  the  latter  (perhaps  neuridin  or  saprin) .  These  bodies 
occur  at  the  same  time  in  the  faeces  of  such  patients,  while  both 
urine  and  faeces  of  healthy  persons  are  free  from  them.  It  is  pos- 
sible, therefore,  that  they  originate  in  a  special  form  of  intestinal 
infection,  and  are  absorbed  from  the  alimentary  canal  and  eliminated 
together  with  cystine  in  the  urine. 

Clinical  Aspects. 

But  little  can  be  said  upon  the  clinical  aspects  of  cystinuria.  The 
substance  has  been  known  to  have  been  passed  intermittently  in  the 
urine  for  years  without  visible  impairment  of  the  bodily  functions, 
but  usually  there  are  marked  signs  of  deterioration  of  the  general 
health,  and  the  nutrition  is  bad.  It  has  been  noticed  in  tubercular, 
anaemic  and  chlorotic  patients.  The  influence  of  debilitating  agencies 
in  increasing  the  deposit  was  most  pronounced  in  Barry's  case.  Its 
most  marked  clinical  aspect  is  the  tendency  which  it  exhibits  to  be 
hereditary.  Golding  Bird  mentions  a  series  of  cases  of  cystine 
calculus  appearing  in  three  successive  generations. 

Dr.  Marcet  mentions  two  brothers  who  died  with  renal  cystine 
calculus.  Lenoir  and  Civiale  extracted  cystine  calculi  from  the 
bladders  of  two  brothers.  Teale  cut  a  boy  for  cystine  stone  and  two 
of  his  brothers  had  cystinuria.  Dr.  Joel  found  cystine  in  a 
mother  and  two  daughters.  Poland  says  that  out  of  twenty-two 
collected  cases  of  cystine  calculi  ten  occurred  in  four  families,  while 
in  three  cases  the  subjects  were  brothers. 


622  FENWICK — DISEASES  OP  THE   URINE. 

Drs.  Picchini  and  Conti  relate  tlae  following  case,  which  is  given 
as  an  example  of  tlie  many  factors  which  may  be  at  work  in  produc- 
ing this  metabolic  modification : 

The  patient  was  a  woman  aged  twenty -nine,  who  had  good  health 
until  the  age  of  nineteen,  when  she  had  acute  rheumatism ;  at  twenty- 
two  she  had  another  attack,  accompanied  by  cardiac  and  pleural 
troubles  from  which  she  never  subsequently  became  quite  free.  At 
twenty -nine  she  was  attacked  by  subacute  polyarthritis  rheumatica, 
with  joint  deformities,  pleural  effusion,  dry  pericarditis,  and  general 
cardiac  hypertrophy  with  mitral  stenosis.  She  had  also  a  febrile 
temperature,  and  her  liver  became  considerably  enlarged.  The  urine 
was  scanty,  200  to  300  c.c,  and  showed  a  trace  of  albumin  with  hyaline 
casts  and  many  leucocytes,  also  a  trace  of  urobilin ;  the  sediment  con- 
tained abundant  crystals  of  cystine.  The  bladder  was  found  on  sound- 
ing to  be  free  from  calculi.  Her  condition  imj)roved  greatly  during 
her  stay  in  the  hospital ;  the  liver  became  reduced  in  size,  the  fever 
disappeared,  also  the  urine  became  free  from  casts  and  albumin  and 
increased  in  amount  to  about  normal.  The  cystine,  however,  was  never 
absent.  The  total  amount  of  cystine  varied  with  the  qiiantity  of  urine 
passed  and,  contrary  to  what  was  noted  in  Ebstein's  case,  more  of  it 
was  secreted  in  the  day  than  at  night.  A  nitrogenous  diet  made  no 
difference,  but  milk  increased  the  amount  of  cystine.  Uric  acid  was 
increased  during  the  day  and  lessened  during  the  night,  while  urea 
was  generally  diminished. 

Cystine  calculi  do  not  differ  in  their  clinical  characters  from  other 
forms.  The  following  case  which  came  under  the  care  of  my  col- 
league, Mr.  Heycock,  is  interesting  as  showing  a  gouty  diathesis  and 
as  presenting  the  largest  cystine  calculus  on  record. 

M.  N.,  aged  50,  was  admitted  into  St.  Peter's  Hospital,  Lon- 
don, with  a  history  of  calculous  symptoms  for  the  past  nine  months. 
He  had  been  fairly  well  except  for  attacks  of  gout  in  the  knees  and 
hand,  from  which  he  had  suffered  twice  a  year  during  the  last  fifteen 
years.  His  bladder  had  been  washed  out  and  sounded  by  various 
medical  men.  The  prostate  was  much  enlarged,  the  urine  showed  a 
specific  gravity  of  1.015 ;  it  was  acid,  and  contained  a  good  deal  of  pus, 
albumin,  and  cystine.  Median  cystotomy  was  performed  and  the 
stone  crushed  with  difficulty  after  Dolbeau's  method.  The  fragments 
were  soft  and  waxy,  of  a  slight  fawn  color,  and  showed  no  concentric 
lines  of  increment.  The  weight  proved  to  be  two  and  one-quarter 
ounces.     The  patient  recovered. 


Treatment. 

Unfortunately  we  have  not  advanced  further  in  our  methods  of 
combating  this  disorder  than  we  have  in  the  exact  knowledge  of  its 
pathology.     The  greatest  benefit  thus  far  obtained  has  resulted  from 


PHOSPHATURIA.  623 

the  employment  of  syrup  of  the  iodide  of  iron,  or  of  nitro-muriatic 
acid,  combined  with  sea-bathing,  exercise,  and  carefully  regulated  diet, 
so  as  not  to  place  undue  stress  upon  the  function  of  the  liver.  As 
Golding  Bird  remarks,  "  We  have  an  obstinate  disease  to  treat,  as  are 
all  ailments  demonstrated  to  be  hereditary.  The  prognosis  must  be 
extremely  guarded  on  account  of  the  tendency  to  form  renal  or  vesical 
calculus."  The  recent  work  upon  intestinal  ptomaines  suggests  some 
correlation  between  cystinuria  and  diaminuria,  and  indicates  the 
therapeutic  employment  of  intestinal  disinfectants.  Mester  has, 
however,  tried  thymol  and  alcohol  as  disinfectants  without  result. 

PHOSPHATURIA. 

The  persistent  and  excessive  elimination  of  alkaline  and  earthy 
phosphates  in  sterile  urine  constitutes  the  symptom  known  as  phos- 
phaturia. 

Phosphaturia  is  often  held  to  include  two  other  and  widely  differ- 
ent conditions,  viz.,  (1)  those  transitory  deposits  of  earthy  phos- 
phates which  occur  in  feebly  acid  or  neutral  urine ;  and  (2)  those 
deposits  of  the  triple  salt,  the  ammonio-magnesium  phosphate,  which 
are  formed  by  the  breaking  up  of  the  urea  in  catarrhal  affections  of 
the  urinary  tract,  the  resultant  carbonate  of  ammonia  combining 
with  the  magnesium  phosphate  in  the  urine  to  form  a  triple  salt. 

It  is  more  logical  and  more  accurate  to  classify  the  two  latter  con- 
ditions under  the  heads  of  "  Functional  Phosphaturia"  and  "  Secon- 
dary Phosphaturia."  For  in  both  these  classes  the  phosphates  are 
in  normal  quantity,  and  are  merely  en  evidence  because  of  the  alkaline 
reaction  of  the  secretion.  The  following  points  will  be  considered 
here: 

The  excretion  of  the  phosphoric  acid  and  its  salts  by  the  urine. 

The  detection  of  phosphates. 

The  estimation  of  phosphoric  acid. 

Functional  phosphaturia. 

Secondary  phosphaturia. 

Tme  phosphaturia. 

The  Excretion  op  Phosphoric  Acid. 

Phosphoric  acid  to  the  amount  of  from  two  to  three  grams  is  ex- 
creted in  the  urine  in  twenty-four  hours.  It  is  combined  partly  with 
sodium,  potassium,  and  ammonium  to  form  soluble  phosphates,  and 
partly  with  lime  and  magnesia  to  form  salts,  which,  though  soluble 
in  the  natural  acid  of  the  urine,  are  (quickly  thrown  down  when  the 


624  FE]srwicK — diseases  of  the  urine. 

secretion  becomes  neutral  or  alkaline.  The  former  group  never  forms 
urinary  deposits,  but  tlie  latter  constitutes  tlie  earthy  phosphates 
which  are  the  chief  features  of  phosphaturia  and  of  advanced  urinary 
concretions.  It  is  unnecessary  to  make  a  separate  estimation  of  these 
two  groups,  in  order  to  gauge  accurately  an  excessive  elimination  of 
phosphate.  It  is  sufficient  to  estimate  the  amount  of  phosphoric 
acid. 

The  Earthy  Phosphates. — Phosphoric  acid  is  spontaneously  de- 
posited in  the  urine  in  one  of  the  three  following  combinations 
(Roberts) :  1.  Amorphous  phosphate  of  lime,  or  bone  earth 
(Ca3(P0,),);  2.  Crystallized  phosphate  of  lime  (CaHP0,+2Aq) ; 
3.  The  triple  phosphate,  ammonio-magnesium  phosphate  (Mg- 
NH,P0,+6Aq). 

1.  Amorphous  Phosphate  of  Lime. — The  occurrence  of  this  deposit 
merely  denotes  that  the  urine  has  been  rendered  alkaline  by  a  fixed 
alkali,  as  when  the  carbonates  of  potash  and  soda  are  present  in  ex- 
cess. It  forms  an  amorphous  white  flocculent  deposit,  which  is 
increased  by  heat  and  dissolves  rapidly  in  any  acid.  There  is  gen- 
erally an  iridescent  film,  "  a  gas  tank"  film  on  the  surface.  Micro- 
scopically, the  deposit  consists  of  minute  granules  aggregated  into 
clumps. 

It  is  chiefly  found  in  patients  who  have  taken  large  doses  of 
alkalies.  It  is  the  normal  deposit  of  alkaline  urine,  and  its  clinical 
significance  and  treatment  depend  on  the  cause  of  the  alkalinity  of 
the  urine. 

2.  CrystalUzed  Phosphate  of  Lime,  or  Stellar  Phosp>hates. — The 
occurrence  of  a  deposit  of  stellar  phosphates  is  rare.  Hassall  first 
called  attention  to  this  form  of  urinary  deposit  in  1860,  and  Sir  Wil- 
liam Roberts,  who  re-examined  the  question  in  1862,  reported  as 
follows : 

The  prevailing  appearance  is  that  of  crystalline  rods  or  needles, 
either  lying  loose  or  grouped  in  stars,  rosettes,  fans,  or  sheaf-like 
bundles  {vide  Fig.  68) .  Some  of  the  crystals  are  club-  or  bottle-shaped 
and  abundantly  marked  with  lines  of  secondary  crystallization. 

The  occurrence  of  a  deposit  of  the  stellar  phosphate  in  urine  is 
not  common.  It  is,  in  fact,  a  rare  deposit  as  compared  with  oxalate 
of  lime,  uric  acid,  or  the  triple  phosphate. 

The  presence  of  this  deposit  in  any  quantity  is,  according  to  Sir  W. 
Roberts,  an  accompaniment  of  some  grave  disorder.  He  has  met 
with  it  in  diabetes,  cancer  of  the  pylorus,  once  in  phthisis,  and  more 
than  once  in  patients  exhausted  by  obstinate  chronic  rheumatism. 
The  crystals  may,  however,  under  peculiar  conditions,  be  precipi- 
tated in  healthy  urine.     "  When   the  urine  is  rich  in  lime,  and  its 


PHOSPHATURIA. 


625 


acidity  is  at  the  same  time  depressed  to  near  the  neutral  line,  stellaB 
of  phosphate  of  lime  may  form  quite  independently  of  any  grave  dis- 
order, merely  as  the  result  of  a  coincidence  in  the  chemical  comiDosi- 
tion  and  reaction  of  the  urine;  for  example,  if  after  a  full  meal  the 
acidity  of  the  urine  becomes  greatly  reduced,  and  lime  derived  from 
the  food  is  present  in  excessive  proportion.  Under  such  circumstan- 
ces, I  have  several  times  detected  stellse  of  phosphate  of  lime,  but 
only  in  small  numbers.     A  depressed  acidity  of  the  urine  is  an  es- 


FiG.  68.— stars  and  rods  of  crystallized  phosphate  of  lime,  or  stellar  phosphate.     (Roberts.) 


sential  contingent  to  the  formation  of  these  crystals,  and  if  the  urine 
subsequently  to  their  formation  increase  in  acidity,  they  may  spon- 
taneously disappear." 

3.  The  Phosphate  of  Ammonm  and  Ifagnesia,  or  the  Triple  Phos- 
phate.— This  insoluble  crystalline  comjjound  is  most  usually  encoun- 
tered with  the  amorphous  phosphate  of  lime.  It  is  easily  soluble  in 
acids,  and  yet  it  may  be  found  in  urine  which  is  feebly  acid.  If 
alone,  the  deposit  has  a  fine  crystalline,  sugar-like  appearance,  and 
sparkling  crystals  may  float  in  the  urine  and  adhere  to  the  sides  of 
the  vessel  or  form  a  glaze  upon  the  surface.  The  usual  form  is  the 
well-known  coffin-lid-like  crystal,  a  triangular  prism  with  bevelled 
ends,  but  the  edges  and  sides  are  often  eroded  by  the  action  of  an 
acid  flow  from  the  healthy  kidneys,  and  the  crystals  assume  a  great 
variety  of  appearance  in  consequence.  I  have  encountered  this  rare 
dei)Osit  alone  and  in  fresh  non-ammoniacal  urine  a  few  times  only  in 
Vol.  I.— 40 


626  FENWICK— DISEASES  OP  THE  UEINE. 

surgical  practice.  The  most  startling  instance  was  in  a  boy  aged 
eight  who  consulted  me  on  account  of  hsematuria  of  a  painless  and 
profuse  character,  which  was  proved  to  be  due  to  fibro-sarcomatous 
polypi  of  the  bladder.  It  is  most  often  met  with  in  urine  which  has 
become  alkaline  from  volatile  alkali.  *  This  depends  on  the  breaking 
up  of  the  urea  into  carbonate  of  ammonia,  by  means  of  a  ferment 
(micrococcus  urese)  generally  introduced  by  the  surgeon  and  increased 
by  the  alkaline  conditions  and  the  mucous  discharge  from  the  bladder 
which  it  excites.  Carbonate  of  ammonia  at  once  throws  down  the 
earthy  salts,  and  the  triple  salt  of  ammonio-magnesium  phosphate 
results.  Sometimes  when  a  large  amount  of  pus  is  present  it  may  be 
acted  upon  by  the  alkalies  to  produce  thick  ropy  masses  of  muco- 
pus.  It  affords  at  one  and  the  same  time  an  evidence  of  fermen- 
tation, of  ammoniacal  urine,  and  of  some  severe  catarrhal  affection 
of  the  urinary  tract. 

Detection  op  Phosphates. 

The  urine  is  treated  with  caustic  potash  and  heated.  The  phos- 
phates are  precipitated  as  eai-thy  i^hosphates.  By  the  addition  of 
ammonia  they  may  be  precipitated  without  heat.  The  amount  of 
deposit  seen  on  cooling  is  a  rough  but  practical  bedside  test  of  the 
quantity  of  earthy  phosphates  present  in  the  urine. 

To  detect  the  presence  of  phosphoric  acid  in  combination  with 
alkalies,  the  urine  is  treated  with  ammonia  and  filtered,  and  to  the 
filtrate  an  ammoniacal  solution  of  magnesia  and  ammonia  is  added, 
whereby  the  phosphates  are  precipitated  as  triple  phosphates. 

Another  method  is  to  treat  the  filtrate  with  acetic  acid,  when  the 
further  addition  of  uranium  solution  yields  a  yellowish  white  pre- 
cipitate. 

The  same  filtrate  with  perchloride  of  iron  solution  gives  a  white 
precipitate,  which  becomes  yellow  on  the  addition  of  more  per- 
chloride. 

Estimation  op  Phosphoric  Acm.f 

To  urine  which  contains  the  phosphates  as  acid  phosphates,  a 
solution  of  uranium  acetate  or  nitrate  is  added  until  an  excess  of  the 
reagent  first  becomes  appreciable.  If  the  nitrate  be  used  free  nitric 
acid  is  formed,  and  causes  a  part  of  the  precipitated  uranium  phos- 

*  Volatile  alkaline  urine  is  so  called  because  the  blue  stain  which  it  gives  to  red 
litmus  disappears  on  drying.  Fixed  alkaline  urine,  on  the  other  hand,  imparts  a 
permanent  blue  stain  to  red  litmus. 

f  From  von  Jaksch. 


PHOSPHATUKIA.  627 

phates  to  redissolve.  To  prevent  this,  in  practice  a  little  sodium  ace- 
tate is  added  to  the  urine  before  titration  with  uranium  nitrate.  As 
an  indicator  a  little  tincture  of  cochineal  is  employed.  This  yields 
a  green  precipitate  in  presence  of  a  uranium  salt  in  excess.  Instead 
of  the  cochineal  fluid  a  solution  of  potassium  ferrocyanide,  1  in  10, 
may  be  used.  This  reagent  deposits  a  deep-brown  precipitate  with 
a  mere  trace  of  uranium  salt.  This  test,  however,  is  less  sensitive 
in  the  presence  of  acetate  of  soda  than  in  simple  watery  solutions. 
Hence  it  is  necessary  to  use  a  definite  quantity  of  the  salt,  and  to 
take  care  that  the  proportion  is  maintained  in  preparing  the  titra- 
tion fluid. 

The  solutions  required  for  this  process  are : 

1.  Solution  of  Acetate  of  Soda. — One  hundred  grams  of  acetate  of 
soda  are  dissolved  in  800  c.c.  of  water,  100  c.c.  of  a  30-per-cent.  solu- 
tion of  acetic  acid  are  added,  and  the  mixture  is  then  made  up  to  a 
litre.     Five  cubic  centimetres  are  employed  with  50  c.c.  of  urine. 

2.  Cochineal  Tincture. — A  cold  infusion  is  made  of  a  few  grams  of 
cochineal  in  a  quarter  of  a  litre  of  a  fluid  composed  of  three-fourths 
parts  of  water  with  one  of  alcohol,  and  the  solution  filtered  for  use, 

3.  Solution  of  Uranium  Oxide. — About  20.3  gm.  of  commercial 
uranium  oxide,  purified  and  well  dried,  is  dissolved  in  pure  acetic 
acid,  or  in  the  smallest  possible  quantity  of  nitric  acid,  and  the  prep- 
aration is  then  made  up  to  a  litre.  Of  the  mixture  1  c.c.  indicates  5 
mgm.  of  phosphoric  acid. 

4.  A  Solution  Containing  a  Definite  Quantity  of  Pliosplioric  Acid. — 
Fifty  cubic  centimetres  should  contain  precisely  0.1  gm.  P,0^.  The 
preparation  is  made  by  dissolving  10.085  gm.  of  neutral  phosphate 
of  soda  in  a  litre  of  water.  The  commercial  salt  should  be  crystal- 
lized from  solution  to  obtain  it  free  from  chlorine,  so  that  no  precipi- 
tate forms  with  nitrate  of  silver  and  nitric  acid.  The  crystals  are 
then  placed  on  paper  in  a  funnel,  the  neck  of  which  is  stopped  with 
glass  wool,  and  allowed  to  docj  there  until  the  mother  liquor  is  no 
longer  found  to  adhere  to  them.  A  known  weight  is  then  taken  and 
rubbed  up  in  a  mortar  and  a  portion  of  the  powder  submitted  to  a 
gentle  heat  in  a  platinum  crucible,  and  finally  incinerated.  Two  hun- 
dred and  sixty-six  grams  of  sodium-pyrophosphate,  Na^P^O,,  cor- 
respond to  716  gm.  Na2HPO,+12H,0.  Consequently  that  quantity 
of  the  dried  crystals  which,  when  incinerated,  yields  266  gm.  corre- 
sponds to  71G  gm.  of  pure  phosphate  of  soda. 

Titration  Process. 

Fifty  cubic  centimetres  of  the  phosphatic  solution  (4)  are  meas- 
ured in  a  flask,  5  c.c.  of  the  solution  of  acetate  of  soda  (1)  and  a  few 


628  FENWICK— DISEASES  OF  THE  URINE. 

drops  of  cochineal  tincture  (2)  are  added,  tlie  mixture  is  boiled,  and  the 
uranium  solution  (3)  is  gradually  supplied  until  the  mixture  becomes 
slightly  but  permanently  green  on  shaking.  In  the  process  a  high 
temperature  should  be  maintained,  to  promote  the  formation  of 
uranium  phosphates.  When  ferrocyanide  of  potassium  is  used  as 
the  indicator,  the  addition  of  the  uranium  solution  is  suspended  when 
the  precipitate  ceases  to  form.  The  fluid  is  again  heated  and  a  drop 
is  tested  by  adding  to  it  a  drop  of  ferrocyanide  in  a  porcelain  capsule. 
The  further  supply  of  uranium  solution  is  regulated  by  the  earliest 
appearance  of  a  brown  color  in  the  specimens  successively  tested. 

The  uranium  solution  is  now  diluted  according  to  the  quantity 
found  to  be  necessary,  as  above,  in  such  proportion  that  20  c.c.  shall 
just  suffice  for  the  titration  of  50  c.c.  of  the  phosphoric  acid  solution. 

Now,  50  c.c.  of  the  phosphoric  solution  represents  0.1  gm.  P^O,, 
and  consequently  20  c.c.  of  the  diluted  uranium  solution  also  corre- 
sponds to  0.1  gm.  P2O5. 

The  titration  process  is  repeated  with  the  urine  in  precisely  the 
same  manner  as  before:  50  c.c.  are  taken,  5  c.c.  acetate  of  soda  and 
a  little  cochineal  added,  and  the  mixture  heated  and  the  terminal 
reaction  sought. 

Every  cubic  centimetre  of  the  uranium  oxide  solution  employed 
in  titration  represents  5  mgm.  P^Oj,.  Hence  the  jDhosjjhoric  acid 
contained  in  55  c.c.  of  urine  may  be  calculated  by  multiplying  the 
number  of  cubic  centimetres  of  uranium  oxide  solution  used  by  0.005. 
The  result  is  the  quantity  of  pliosi:)horic  acid  in  grams  contained 
in  50  c.c.  of  urine.  It  is  advisable  in  each  case  to  make  two  such 
investigations  and  to  take  the  mean  of  their  results. 

Transient  Phosphatic  Urine. 

In  this  class  the  urine  does  not  contain  phosphates  in  excess.  Its 
normal  quantum  of  amorphous  phosphate  of  lime  (bone  earth)  is 
merely  thrown  down  by  reason  of  an  increased  alkalinity  of  the  urine. 

It  may  appear  in  patients  in  complete  health,  who  have  indulged 
in  sweet  or  sub-acid  fruits,  or  in  sparkling  beverages,  or  it  occurs  in 
those  who  are  suffering  from  the  depressing  effects  of  sexual  indul- 
gence or  habitual  masturbation.  Those  whose  urine  has  been  ren- 
dered alkaline  by  medicines,  such  as  the  carbonates,  the  acetates, 
and  the  citrates  of  the  alkalies  also  pass  heavy  deposits  of  earthy  phos- 
phates. The  urine  may  be  turbid  only  once  and  during  the  rest  of 
the  day  it  may  be  quite  clear.  At  other  times  the  turbidity  may 
last  for  several  days,  but  it  is  not  constant,  nor  does  it  produce  any 
marked  symptoms  beyond  a  slight  listlessness  and  loss  of  spirits. 


PHOSPHATUEIA.  629 

Catarrhal  conditions  of  the  prostate  and  bladder,  the  result  of 
gonorrhoea,  may  or  may  not  cause  the  transient  deposition  of 
earthy  phosphates. 

It  is  certain  that  phosphatic  urine  is  often  met  with  in  patients 
suffering  from  posterior  urethritis,  mild  cystitis,  or  pyelitis,  and 
that  these  two  and  independent  troubles  react  upon  and  accentuate 
each  other ;  thus  the  furred,  spongy  surface  of  the  inflamed  mucous 
membrane  resents  the  alkalinity  of  the  urine  and  favors  the  deposi- 
tion of  phosphates  by  further  depressing  the  acidity  of  the  secretion. 
This  reaction  is  carried  out  without  the  formation  of  mucus  or  the 
intervention  of  the  micrococcus  urese,  so  that  the  triple  phosphates 
are  not  discovered  in  the  urine,  but  appear  in  a  later  stage  or  severer 
grade. 

Secondaey  Phosphatic  Deposits  in  Septic  Urine. 

The  phosphatic  deposit  which  is  thrown  down  by  the  volatile 
ammonia  of  decomposition  is  a  combination  of  triple  phosphates 
and  lime  phosphates  with  an  occasional  small  admixture  of  urate 
of  ammonia  and  carbonate  of  lime.  It  is  passed  either  in  whitish 
clumps  mixed  with  mucus,  or  it  is  deposited  on  abraded  and  swollen 
rugae  of  the  bladder,  on  the  salient  parts  of  a  necrotic  growth,  or 
upon  some  nucleus,  such  as  that  afforded  by  a  calculus  or  a  foreign 
body.  The  time  at  which  the  secondary  deposit  commences  is  quite 
uncertain,  depending  as  it  does  on  the  onset  of  cystitis. 

Teue  Phosphatueia.* 

In  true  phosphaturia  the  elimination  of  alkaline  and  earthy  salts 
is  often  greatly  increased;  instead  of  two  or  three  grams  of  phos- 
phoric acid  being  excreted  in  twenty-four  hours,  the  amount  may  rise 
to  seven  or  nine  grams  (Ealfe) . 

This  increase  is  usually  marked  by  the  appearance  of  a  heavy, 
soft,  whitish  deposit  of  phosphate  of  calcium,  generally  of  the  amor- 
phous type,  or  the  urine  may  in  rarer  cases  be  acid  and  without  de- 
posit, and  the  presence  and  amount  of  the  phosphoric  acid  are  discov- 
erable only  when  a  quantitative  estimation  of  that  substance  is  made. 

Dr.  Hassall  attaches  much  importance  to  the  forms  in  which  the 
phosphate  is  deposited,  and  considered  the  crystallized  phosphate  of 
lime  f  as  an  indication  of  grave  constitutional  disturbance.    Although 

*  The  work  done  by  Tessier  and  Ralf e  in  phosphatic  diabetes  has  been  freely 
drawn  upon  by  the  writer  of  this  article. 

f  The  formation  of  these  crystals  simply  depends  on  the  amount  of  lime  present 
and  the  degree  of  acidity  of  the  urine.     They  can  generally  be  produced  by  the  ad- 


630  FENWICK — DISEASES  OE  THE  URINE. 

Bence  Jones  and  Dickinson  combat  this  view,  they  agree  as  to  the 
correlation  which  Prout  pointed  out  as  existing  between  nervous  irri- 
tation and  exhaustion  and  the  excessive  output  of  phosphate  of  lime. 
It  is  still  uncertain  as  to  whether  the  constitutional  disturbance 
is  not  more  connected  with  the  lime  constituent  than  with  the 
phosphate. 

Clinical  Features  and  Symptoms  of  Phosphaturia. 

These  vary  greatly,  depending  probably  upon  the  grade  of  the 
loss  and  the  length  of  time  during  which  it  has  existed.  Most 
writers  have  a  sharply  stamped  clinical  picture  of  the  type  of  patient 
who  is  thus  suffering.  Thus  Dickinson  says :  "  I  have  learnt  to  rec- 
ognize the  manner  of  a  man  who  is  suffering  from  phosphaturia. 
He  is  nervous  and  mobile,  of  hj^pochondriacal  temperament,  having 
perhaps  half  latent  gouty  characteristics." 

The  symptoms  include  the  phenomena  of  nervous  irritability,  of 
functional  derangement  of  the  digestive  organs,  and  of  widespread  and 
obstinate  neuralgias,  especially  those  of  the  pelvic  viscera.  Thus 
patients  may  be  emotional,  excitable,  extremely  wakeful,  they  are 
tortured  by  presentiments  and  i)rofoundly  depressed  and  melan- 
cholic. Yertigo  is  sometimes  complained  of,  the  gait  is  unsteady, 
the  hands  tremulous.  The  tongue  is  pale  and  flabby,  deeply  in- 
dented by  the  teeth  or  coated  with  a  white  and  moist  fur.  Anorexia 
and  constipation  are  usually  complained  of.  Abnormal  sensations, 
such  as  numbness  of  the  legs  or  vague  backaches  or  limb  weariness, 
are  generally  present.  The  urine  is  usually  increased  in  amount, 
frequency  of  micturition  being  observed  in  consequence,  and  there  is 
also  the  vesical  irritability  (urethral  burning)  which  is  the  direct 
outcome  of  phosphatic  irritation.  The  whole  urinary  tract  sym- 
pathizes, but  the  chief  section  to  bear  the  discomfort  is  the  vesical 
neck.  As  the  case  progresses  it  is  said  to  become  similar  in  some 
respects  to  diabetes  insipidus.  In  fact  Tessier  has  proposed  to  give 
the  name  of  phosphatic  diabetes  to  this  complaint. 

Ralfe,  to  whom  we  owe  a  valuable  addition  to  our  knowledge  of 
the  subject,  records  a  number  of  well-marked  cases,  from  which  the 
following  two  examples  are  taken : 

Increased  Elimination  of  PJiospJioric  Acid;  Moderate  Polyuria, 
Hypochondriasis,  Rheumatic  Pains  in  the  Loins;  Emaciation. — A  small 
but  well-built  man,  aged  25,  attributes  his  illness  to  overwork.  No. 
history  of  syphilis.  Temperate  habits;  has  a  pale,  anxious,  hag- 
ministration  of  lime  or  its  vegetable  salts  until  the  urine  becomes  charged  with  lime, 
while  its  acidity  is  lessened  (Dickinson,  "Eeual  Affections,  "  vol.  iii.,  p.  1,234). 


PHOSPHATURIA.  631 

gard  expression.  States  that  he  has  been  ailing  for  some  months, 
has  lost  flesh,  and  complains  of  a  feeling  of  extreme  nervousness 
and  exhaustion,  with  frequent  fits  of  trembling.  Constant  tear- 
ing pains  in  the  loins,  often  shooting  round  the  pelvic  region  with 
cramp-like  spasms  in  the  lower  parts  of  the  abdomen. 

No  lightning  pains,  patellar  reflex  unimpaired.  Vision  perfectly 
distinct.  No  apparent  disease  of  the  abdominal  or  thoracic  viscera. 
Digestion  fairly  good,  bowels  constipated.  Urine  pale,  whey-like, 
of  medium  specific  quantity,  alkaline  reaction,  no  sugar,  no  albumin. 
Patient  states  that  he  passes  more  urine  than  he  should  and  is  fre- 
quently disturbed  at  night  to  void  it.  He  was  instructed  how  to  collect 
and  measure  it,  and  was  told  to  bring  a  sample  of  the  mixed  twenty-four 
hours'  urine  at  the  next  visit.  He  did  not  comply  with  all  the  con- 
ditions necessary  for  accurate  measurement,  and  it  was  not  until 
October  21st  that  satisfactory  evidence  was  given  that  the  instruc- 
tions had  been  carefully  carried  out.  By  that  time  he  had  been  five 
weeks  under  treatment  with  mineral  acids  and  nux  vomica,  and  had 
improved  to  some  extent. 

Analysis  of  Urine  Passed  in  Tiuenty-four  Hours.- — October  21st: 
Quantity  2,3d0  c.c,  sp.  gr.  1.015,  reaction  alkaline.  Phosphoric  acid 
5.8  gm.  or  nearly  treble  what  it  should  be  for  a  man  of  his  weight. 
Ordered  codeine  pill,  one-third  of  a  grain,  and  a  mixture  of  bro- 
mide of  potassium  and  nux  vomica. 

November  18th :  Very  much  improved,  is  gaining  weight,  feels 
stronger,  has  nearly  lost  the  pains ;  the  discharge  of  urine  is  still  more 
abundant  than  it  should  be.  The  patient  is  to  collect  and  measure  as 
before  and  to  bring  a  sample  at  his  next  visit.  To  continue  the  mix- 
tures but  to  leave  off  the  codeine. 

November  25th:  Analysis  of  urine:  Quantity  2,300  c.c,  sp.  gr. 
1.015,  reaction  alkaline,  phosphoric  acid  5.8  gm. 

Excessive  Elimination  of  Fhosphoric  Acid,  No  Polyuria,  Hypochon- 
driasis, Enormous  Quantities  of  Calcium,  Oxalate  in  the  Urine. — A  gen- 
tleman's servant,  aged  27.  First  came  under  observation  September 
28th,  1880.  He  is  a  thin,  spare  man  weighing  about  120  pounds,  of  a 
sallow,  haggard  complexion.  No  history  of  syphilis ;  habits  temper- 
ate. Complains  of  aching  pains  especially  in  the  loins,  shooting 
down  the  hips,  and  occasionally  affecting  the  bladder  and  testicles. 
Alleged  loss  of  virile  power.  Abdominal  organs  and  thoracic 
organs  apparently  healthy.  Digestion  fair,  bowels  constipated. 
Feels  very  wretched  and  depressed.  Urine  passed  at  the  time  of 
visit  (11  A.M.)  acid,  sp.  gr.  1.028,  containing  8  gm.  of  phosphoric 
acid  in  1,000 c.c.  The  secretion  of  urine,  he  said,  was  not  excessive; 
he  was  rarely  troubled  during  the  day  but  frequently  at  night  with 
calls  to  micturate.  He  was  requested  to  collect  and  measure  the 
urine  for  a  few  days,  and  send  a  note  with  regard  to  the  quantity 
passed  in  the  twenty-four  hours.  This  proved  to  be  just  under  two 
pints,  or  about  1,100  c.c.  The  urine  he  passed  at  the  time  of  his 
visit  deposited  in  a  few  hours  an  enormous  quantity  of  oxalate  of 
lime,  but  contained  no  sugar,  no  albumin.  Ordered  codeine  pill,  a 
quarter  of  a  grain,  at  night,  and  a  mixture  of  hydrochloric  acid  in  nux 
vomica  and  cod-liver  oil. 


6S2  I^FWICK — DISEASES  OF  THE  URINE. 

November  18tli:  Is  mucli  better.  Less  pain  in  loins,  is  not  so 
despondent,  thougli  lie  still  fears  lie  is  impotent ;  confesses,  however, 
to  occasional  manifestations  of  "  his  natnre."  To  discontinue  codeine 
and  to  take  pliosphorns  pills,  one-sixtieth  of  a  grain  instead.  To 
collect  urine  for  twenty-four  hours,  and  to  send  it  for  examination. 

December  1st:  Quantity  1,520  c.c,  sp.  gr.  1.022.  Urea  41.2 
gm.,  phosphoric  acid  5.2  gm.     Still  under  observation. 

Causation. 

Our  knowledge  of  the  causes  for  the  increased  production  of  phos- 
phate is  scanty.  Nor  is  it  certain  whether  the  train  of  symptoms 
ascribed  to  the  loss  is  due  to  the  lime  or  to  the  phosphatic  constitu- 
ents of  the  bone  earth. 

The  following  clinical  clues  are,  however,  established : 

The  Sources  of  the  Lime  and  Phosphates. — In  osteomalacia,  the 
urine  contains  from  three  to  four  times  the  amount  of  earthy  phos- 
phates that  it  normallj'"  eliminates.  The  phosphaturia  is  constant 
and  not  periodical.  That  the  supply  is  derived  from  the  bones  is 
obvious,  from  the  following  estimate  of  lime  salts  in  bone :  In  normal 
bone  there  is  from  60.5  to  70.2  per  cent,  of  lime  salts.  In  osteoma- 
lacia 29.17  per  cent.  In  the  last  stages  of  osteomalacia  1.83  per  cent. 
So  great  is  the  deposit  of  phosphate  of  lime  in  the  urine  that  stones 
form  in  the  kidnej^s  and  even  the  bladder,  except  when  disease  of  the 
kidneys  checks  the  output,  in  which  case  the  deposit  of  the  lime  salts 
is  found  in  other  organs. 

In  rickets  the  bones  soften  and  bend,  often  to  a  remarkable  extent, 
proving  clinically,  what  has  been  established  chemically,  that  the 
withdrawal  of  the  lime  salts  is  great.  In  these  cases  also  phospha- 
turia is  noticed  at  some  time  or  other  in  the  course  of  the  disease,  and 
the  phosphates  may  rise  to  four  or  five  times  the  normal  amount. 
Although  they  are  not  always  deposited  as  earthy  phosphates,  yet 
they  are  held  in  solution  by  the  large  amount  of  lactic  acid  which  is 
present  in  the  urine. 

As  a  link  in  the  chain  of  associated  conditions  the  following  sta- 
tistics by  Neumann  may  be  mentioned :  He  collected  327  cases  of 
fracture  of  the  bones  (fragilitas  ossiumj,  these  fractures  having  for 
the  most  part  taken  place  spontaneously  and  the  brittleness  being 
due  to  the  removal  of  the  lime  salts.  Paralytic  dementia  occurred 
in  39.1  per  cent. ;  imbecility  in  28.1  per  cent. ;  mania  in  17.2  per 
cent. ;  melancholia  in  6.3  per  cent. ;  psychic  insanity  in  3.1  per  cent. ; 
other  forms  of  mental  disease  in  1.6  per  cent. 

Phosphaturia  was  noticed  in  acute  meningitis  by  Pence  Jones,  and 
in  acute  paroxysms  of  certain  forms  of  mania  by  Sutherland  and  Beale. 


OXALURIA.  633 

PJiosphaturia  has  also  been  observed  as  a  symptom  occurring 
in  progressive  pernicious  anaemia  and  preceding  or  accompany- 
ing such  debilitating  diseases  as  phthisis,  cancer,  and  diabetes 
mellitus. 

These  observations  are  yet  too  limited  to  draw  general  conclusions 
from.  We  are,  however,  in  a  position  to  connect  the  appearance  of 
j)hosphaturia  with  the  destruction  and  waste  of  some  tissue  of  the 
body.  But  whether  in  these  conditions  "  it  is  due  to  increased  meta- 
morphosis of  nervous  matter  or  to  the  irritation  of  a  still  hypotheti- 
cal co-ordinating  chemical  centre,"  or  to  the  influence  of  a  disturbed 
condition  of  the  nervous  system  upon  nutrition  generally,  it  is  at 
present  impossible  to  decide  (Ralfe) . 

Treatment. 

The  treatment  of  phosphaturia  must,  of  course,  depend  on  an  ap- 
preciation of  the  exact  cause,  if  this  can  be  ascertained. 

If  the  patient  has  had  syphilis,  the  iodides  and  mercury  may  be 
tried,  but  they  rarely  give  satisfactory  results,  and  more  can  be  done 
by  cod-liver  oil  and  tonics.  The  excessive  output  of  phosphates  must 
be  controlled  if  possible,  and  the  general  health  improved.  A  change 
to  a  dry  bracing  climate,  the  use  of  warm  clothing,  and  of  light,  nu- 
tritious food,  especially  milk,  is  often  sufficient  to  produce  a  marked 
improvement. 

Drugs. — Opium  or  codeine  is  useful  in  all  stages  of  phosphaturia. 
At  the  onset  it  may  be  given  with  a  free  hand,  but  later  on  it  must 
be  sparingly  administered,  on  account  of  the  digestive  troubles  to 
which  it  gives  rise.  Codeine  is  perhaps  more  useful  in  treating  the 
polyuria  which  often  accompanies  the  later  stages  of  phosphaturia. 
Tonics  are  especially  valuable,  chief  among  them  being  acids  and 
nux  vomica  or  its  equivalent  strychnine.  Quinine  and  iron  take  a 
subsidiary  place.  Maltine  and  cod-liver  oil  are  often  of  great  value. 
Warm  baths  followed  by  tepid  douches  are  said  by  Ralfe  to  give  great 
relief  to  the  neuralgic  pain,  as  well  as  to  be  calmative  to  the  nervous 
system. 

OXALURIA. 

Definition. — The  persistent  appearance  of  a  decided  amount  of 
oxalate  of  lime  crystals  in  the  urine  constitutes  the  symptom  known 
as  oxaluria.  The  question  of  an  oxalic  acid  diathesis  or  the  passage 
of  oxalate  of  lime  in  a  crystalline  form,  and  associated  with  decided 
nervous  and  dyspei)tic  symptoms,  was  raised  by  Golding  Bird  in 
1842. 


634  FENWICK — DISEASES  OF  THE  URINE. 

Writing  in  1853,  this  keen  observer  and  able  clinician  still  held  to 
his  original  opinion  in  the  face  of  much  opposition,  and  declared, 
moreover,  that  deposits  of  oxalate  of  lime  were  of  far  more  frequent 
occurrence  in  the  urine  than  those  of  earthy  phosphates.  There  is 
now  no  doubt  that  oxalate  of  lime  exists  in  normal  urine,  also  that 
persons  in  perfect  health  pass  oxalate  of  lime  crystals  in  small  quanti- 
ties. Moreover,  when  these  crystals  appear  in  larger  quantities  no 
associated  symptoms  may  be  present,  this  being  well  exemplified  in 
children  and  adults  with  oxalate  of  lime  calculi.  It  is  also  admitted, 
however,  as  equally  certain,  that  there  is  a  peculiar  train  of  nervous 
and  dyspeptic  symptoms  often  associated  with  the  passage  of  oxalate 
of  lime,  and  that  the  term  oxaluria  nervosa  or  idiopathic  oxaluria, 
used  to  express  this  condition,  is  valuable  and  distinctive  as  a  clinical 
designation. 

Micro-Chemical  Tests. 

Oxalic  acid  (C^H^OJ  is  present  in  the  urine  in  minute  quantities 
in  combination  with  potash,  soda,  and  lime,  two  centigrams  being 
passed  in  twenty -four  hours  (Fiirbringer) .  When  in  excess  a  crystal- 
line deposit  of  calcium  oxalate  (CaC„Oj  is  precipitated. 

Microscopically  the  crystals  are  of  two  kinds,  the  more  com- 
mon being  the  distinctive  and  unmistakable,  strongly  refracting  octa- 
hedral crystals  (shaped  like  envelopes).  Much  less  frequently  the 
crystals  assume  a  dumb-bell  shape,  which  is  merely  an  oval  or  circu- 
lar disc  with  rounded  margins,  and  a  depression  in  the  centre  on 
either  face.  These  are  said  by  Ord  to  result  from  slow  precipitation 
in  the  presence  of  colloid  matter.  The  crystals  are  insoluble  in  vegeta- 
ble acids,  alcohol,  ether,  or  water,  but  they  dissolve  readily  in  min- 
eral acids.  Oxalic  acid  is  often  associated  with  uric  acid  and  urates 
(one-third  of  the  cases — Bird) ;  urea  is  also  present  in  greater  propor- 
tion than  natural  (30  per  cent,  of  the  cases — Bird) .  More  rarely  an 
excess  of  phosphates  is  present. 

To  estimate  the  amount  of  oxalic  acid  in  the  urine — for  oxaluria 
as  a  morbid  state  cannot  be  measured  by  the  microscope,  alone,  since 
a  large  proportion  of  oxalic  acid  may  be  in  solution — the  following 
method  is  advised : 

Quantitative  Estimation  of  Oxalic  Acid  (Neubauer^s  Method). 

The  urine  passed  during  twenty-four  hours  is  accurately  measured 
and  treated  first  with  calcium  chloride  and  ammonia,  then  with  acetic 
acid  until  it  has  a  slightly  acid  reaction,  and  afterward  a  little  alcoholic 
solution  of  thymol  is  added  to  restrain  the  development  of  micro- 
organisms.    The  mixture  is  allowed  to  stand  for  some  time,  when 


OXALUEIA.  635 

the  white  precipitate  which,  forms  is  separated  on  a  filter,  and  (to- 
gether with  the  latter)  is  placed  in  hydrochloric  acid,  gently  heated, 
the  fluid  filtered  off,  and  the  filter  washed  with  water  until  it  no  longer 
has  an  acid  reaction.  The  collected  filtrate  is  evaporated  to  a  small 
bulk  in  a  capsule  on  the  water-bath,  then  placed  in  a  strong  glass 
cylinder,  and  the  capsule  in  which  it  was  evaporated  is  washed  with 
dilute  hydrochloric  acid  and  water,  the  washings  being  added  to  the 
fluid  in  the  cylinder.  Ammonia  solution  is  then  poured  upon  the 
surface  of  the  latter,  and  the  whole  is  tinted  with  a  few  drops  of  tinc- 
ture of  litmus.  The  mixture  is  allowed  to  stand  for  a  considerable 
time.  The  precipitate  which  has  formed  is  obtained  on  a  so-called 
ash-free  filter,  the  ash  constituent  of  which  has  been  accurately  as- 
certained, and  the  oxalate  of  lime  which  adheres  to  the  walls  of  the 
cylinder  is  removed  on  a  glass  rod  guarded  with  an  india-rubber 
ring,  and  is  added  to  the  precipitate  on  the  filter.  The  latter  is  next 
freed  from  chlorine  by  washing  with  water  and  rinsing  with  acetic 
acid.  The  filter  is  then  dried  and  ignited  on  a  platinum  crucible, 
which  is  heated  to  a  constant  degree  in  a  blowpipe  flame.  By  this 
means  oxalate  of  lime  is  changed  into  lime.  Now  as  56  parts  of  lime 
correspond  to  90  parts  of  oxalic  acid,  the  quantity  of  the  former  ob- 
tained when  multiplied  by  1.6071  shows  the  quantity  of  oxalic  acid 
in  the  urine  taken.  (Extracted  from  v.  Jaksch,  "  Clinical  Diagnosis," 
translated  by  James  Cagney.) 

Appeahajsice  of  the  Ueine  in  Oyat.ttrta. 

A  deposit  of  oxalate  of  lime  is  generally  imperceptible  to  the 
naked  eye ;  at  most  only  a  slight  cloud  of  mucus  is  perceived.  The 
crystals  are  said  to  be  often  deposited  on  the  sides  of  conical  urine 
glasses,  in  fine  lines  running  transversely  or  obliquely,  giving  the 
appearance  as  if  the  glass  were  finely  scratched,  and  it  is  stated  that 
this  is  distinguished  from  a  similar  ajjpearance  which  uric  acid  as- 
sumes when  crystallizing  on  glass,  by  the  greater  coarseness  of  the 
line  in  the  latter  case  and  its  more  or  less  brown  color  (Roberts) . 

Circumstances  under  which  Oxaiate  of  Lime  is  Deposited. 

The  development  of  this  salt  appears  to  depend  more  upon  the 
lime  present  in  the  urine  than  upon  the  oxalic  acid. 

"  Given  an  excess  of  lime  in  the  urine,  oxalic  acid,  come  it  from 
whence  it  may,  is  seldom  wanting.  If  the  secretion  be  normally  acid, 
much  of  the  lime  will  appear  as  oxalates ;  if  it  be  slightly  acid  or 
ueutral,  as  acid  or  crystalline  phosphate;  if  alkaline,  as  amorphous 
or  basic  j^hosphate.     If,  then,  this  deposit  is  formed  persistently  in 


636  FENWICK — ^DISEASES   OF  THE  URINE. 

copious,  clear,  and  pale  urine,  it  may  generally  be  regarded  as  the 
result  of  secretion,  and  as  a  sign  of  a  constitutional  state.  When  it 
is  found  in  higli-colored  or  uratic  urine  it  may  possibly  have  re- 
sulted from  a  decomposition  of  urates  and  be  without  clinical  signi- 
ficance"  (Dickinson) . 

The  conditions  under  which  oxalate  of  lime  appears  in  the  urine 
may  be  noticed  under  four  headings  (Jaksch) : 

1.  Oxalates  appearing  as  a  physiological  product; 

2.  Oxalates  of  accidental  origin,  or  symptomatic; 

3.  Oxalates  appearing  vicariously ; 

4.  True  oxaluria,  the  so-called  oxaluria  nervosa. 

A  few  remarks  upon  the  first  three  headings  will  be  sufficient. 

1.  Oxalates  Appearing  as  a  Physiological  Product. — As  has  been 
stated,  the  normal  urine  contains  oxalate  of  lime  in  minute  quantities. 
Much  greater,  then,  will  be  the  product  when  oxalic  acid  is  taken 
either  with  the  food  or  with  drugs. 

Lime  Water. — It  is  supposed  that  the  frequency  of  lime  oxalate 
calculi  in  districts  supplied  with  lime-stone  water  is  due  to  the  pres- 
sence  of  this  mineral  in  the  water. 

Drugs  and  Diet. — Oxalic  acid  and  its  compounds,  even  the  insolu- 
ble oxalate  of  lime,  when  introduced  into  the  stomach  pass  into  the 
urine.  Thus  Wohler  (Eoberts,  "Urinary  Diseases,"  4th  ed.,  p.  84) 
found  that  oxalic  acid  given  to  dogs  caused  oxalate  of  lime  to  appear 
in  the  urine. 

Piotrowsky  confirmed  these  results  by  experiments  on  himself. 
He  took  in  divided  doses  from  80  to  100  grains  of  oxalic  acid  in  the 
course  of  six  hours  and  found  that  from  8  to  14  per  cent,  appeared  in 
the  urine  as  oxalate  of  lime  mixed  with  a  little  alkaline  oxalate. 

In  slight  cases  of  poisoning  by  oxalic  acid  much  oxalate  of  lime 
appears  in  the  urine.  Many  fruits,  vegetables,  and  other  articles  of 
diet  contain  this  substance;  such  are  turnips,  onions,  cauliflower, 
tomatoes,  spinach,  sorrel,  endive,  purslain,  carrots,  parsnips,  parsley, 
celery,  asparagus,  apples,  pears,  pomegranates,  grapes ;  also  drinks 
that  contain  carbonic  acid  gas,  as  seltzer  water  and  champagne.  The 
excessive  use  of  sweetmeats  leads  to  an  excretion  of  oxalic  acid,  also 
the  exhibition  of  some  drugs,  such  as  rhubarb,  squills,  gentian,  val- 
erian, and  cinnamon.  The  ingestion  of  any  of  these  by  persons  pre- 
disposed to  the  formation  of  oxalates  causes  the  appearance  of  oxalate 
of  lime  crystals  in  the  urine. 

2.  Oxalates  Appearing  Symptomatically  or  in  the  Course  of  Acute  or 
Chronic  Disease. — The  appearance  of  oxalates  as  the  result  of  increased 
tissue  metabolism  in  the  course  of  acute  or  chronic  disease  is  usually 
transitory  and  without  special  pathological  significance,  for  any  in- 


OXALUEIA.  637 

terference  with  the  digestive  processes  or  with  free  respiration  will 
cause  a  copious  deposit  of  oxalates  in  the  urine. 

It  has  been  noted  in  pulmonary  and  cardiac  affections,  in  icterus 
(Schulzer  and  Fiirbringer) ,  and  in  the  convalescence  of  acute  rheuma- 
tism. In  cases  of  intestinal  and  gastric  catarrh  it  has  been  found 
to  follow  as  a  result  of  a  superabundance  of  amylaceous  or  saccharine 
food.     It  has  also  been  found  in  cases  of  cyclic  albuminuria. 

3.  Oxalates  Appearing  Vicariously. — V.  Jaksch  states  that  oxal- 
uria  may  appear  vicariously  in  diabetes  mellitus. 

Idiopathic  Oxaluria — Oxaluria  Nervosa. 

Putting  aside  what  may  be  termed  the  physiological,  accidental, 
and  vicarious  causes  just  mentioned  for  the  production  of  oxalate  of 
lime  crystals  in  the  urine,  there  remains  a  class  of  cases  in  which  a 
constant  supply  of  this  salt  appears  in  the  urine,  and  it  is  to  this 
class  that  the  terms  oxaluria,  idiopathic  oxaluria,  oxalic  diathesis, 
oxaluria  nervosa  have  been  applied.  It  must  be  acknowledged  that 
we  know  very  little  concerning  the  causes  of  this  condition,  and 
though  the  literature  is  as  abundant  as  it  is  theoretical,  it  is  at  the 
same  time  confusingly  polemic. 

Sir  William  Eoberts  is  strongly  convinced  that  oxaluria  is  only 
one  of  a  long  list  of  symptoms,  and  one  having  the  least  significance, 
and  many  well-known  authorities  support  him  in  this  view.  On  the 
other  hand,  the  opinions  expressed  by  Prout,  Bird,  and  Begbie  are  in- 
dorsed by  many,  such  as  Cantani,  v.  Jaksch,  Peyer,  Ultzmann,  and 
Oberlander.  This  view  is,  that  there  are  certain  complaints  char- 
acterized by  pains  in  the  back  and  loins  attended  by  rapid  emaciation 
in  which  the  only  other  subjective  symptom  is  an  excessive  elimina- 
tion of  oxalic  acid  in  the  urine. 

Dr.  Bird  ("Urinary  Deposits,"  5th  ed.,  p.  251)  gives  the  following 
account  of  the  symptoms  which  accompany  oxaluria:  "They"  (the 
patients)  "are  generally  much  emaciated  excepting  in  slight  cases, 
extremely  nervous,  painfully  susceptible  to  external  impressions, 
often  hypochondriacal  to  an  extreme  degree,  and  in  very  many  cases 
labor  under  the  impression  that  they  are  about  to  fall  victims  to 
consumption.  They  complain  bitterly  of  incapacity  of  exerting 
themselves,  the  slightest  exertion  bringing  on  fatigue.  Some  feverish 
excitement  with  parching  of  the  palms  of  the  hands  and  soles  of  the 
feet,  especially  in  the  evening,  is  often  present  in  severe  cases.  In 
temper  they  are  irritable  and  excitable,  in  men  the  sexual  power  is 
generally  deficient  and  often  absent.  A  severe  and  constant  pain,  or 
sense  of  weight  across  the  loins,  is  generally  a  prominent  symptom, 


638  FENWICK — DISEASES  OF  THE  URINE. 

with  often  some  amount  of  irritability  of  the  bladder.  The  mental 
faculties  are  generally  but  slightly  affected,  loss  of  memory  being 
sometimes  more  or  less  present." 

Cantani  distinguishes  two  forms  of  oxaluria  nervosa,  in  both  of 
which  the  presence  of  oxalate  of  lime  in  the  urine  is  pronounced.  In 
the  first  the  patients  are  emaciated  and  complain  of  a  feeling  of  general 
discomfort  and  of  digestive  disturbances — dyspepsia,  flatulence,  and 
constipation;  of  sleeplessness,  hypochondriasis,  melancholia,  capri- 
ciousness,  bodily  weakness,  loss  of  energy,  diminution  of  mental 
power,  rheumatic  pains.  Often  there  are  progressive  emaciation, 
pain  in  the  kidney  region,  eczema,  and  psoriasis.  The  urine  is  very 
acid  and  concentrated  and  dark,  similar  to  that  passed  in  febrile 
diseases.  It  is  of  a  high  specific  gravity,  and  it  is  often  also  heavily 
charged  with  solids,  uric  acid,  and  urates.  The  second  class  includes 
obese  patients  who  are  troubled  with  the  usual  loin  pains,  but  also 
complain  of  characteristic  neuralgic  lancinating  pain  along  the  whole 
length  of  the  backbone,  and  along  the  extremities.  Gastralgia  is 
also  present.  Small  jjurulent  collections,  such  as  furunculosis,  car- 
buncle, and  abscess,  which  perhaps  result  from  the  blockage  of  the 
capillaries  with  oxalate  of  lime,  are  suffered  from.  Nervous  symptoms 
and  great  weakness  are  marked,  but  the  patient  does  not  emaciate. 
After  an  absolute  flesh  diet  for  some  days  not  only  does  the  oxalate 
of  lime  disappear  from  the  urine,  according  to  Cantani,  but  also  the 
nervous  feelings  gradually  abate.  If  neglected  or  badly  handled  such 
patients  invariably  form  calculi  in  the  bladder  or  kidney. 

Beneke,*  who  has  subjected  this  question  to  an  elaborate  exam- 
ination, in  the  way  of  both  experiment  and  observation,  has  formu- 
lated the  following  propositions : 

1.  Oxaluria,  a  condition  which  accompanies  the  lighter  or  severer 
forms  of  illness,  has  its  proximate  cause  in  an  impeded  metamorpho- 
sis, that  is,  in  an  insufficient  activity  of  that  stage  of  oxidation  which 
changes  oxalic  acid  into  carbonic  acid. 

2.  Oxalic  acid  has,  if  not  its  sole,  its  chief  source  in  the  azotized 
constituents  of  the  blood  and  food;  everything,  therefore,  which 
retards  the  metamorphosis  of  these  constituents  occasions  oxaluria. 

3.  Such  a  retardation  of  the  metamorphosis  of  the  azotized  con- 
stituents of  the  blood  and  food  may  be  determined  by  the  following 
causes : 

a.  Abuse  of  azotized  articles  of  food  (direct  retardation) . 
&.  Abuse  of  saccharine  and    starchy  articles  of    food   (indirect 
retardation) . 

*  Quoted  by  Roberts. 


OXALURIA.  639 

c.  Insufficiency  of  the  red  blood  corpuscles  and  eventually  dimin- 
ished oxidation. 

d.  Insufficient  enjoyment  of  pure,  fresh  air. 

e.  Organic  lesions  which  in  any  way  impede  respiration  and  the 
circulation  of  the  blood. 

/.  Conditions  of  the  nervous  system  which  bear  a  character  of 
depression,  whether  these  arise  primarily  from  mental  derangement  or 
from  pathological  states  of  the  blood. 

4.  Excess  of  alkaline  bases  in  the  blood,  as  numerous  observa- 
tions tend  to  show,  plays  an  important  part  among  the  etiological 
conditions  of  oxaluria ;  and  it  is  not  improbable  that  an  increased 
production  of  lactic  and  butyric  acids  in  the  digestive  canal,  con- 
sequent thereupon,  impedes  the  development  of  the  red  blood  cor- 
puscles, and  thereby  generates  that  chlorotic  state  which  so  often 
occasions  and  accompanies  oxaluria. 

5.  Catarrhal  conditions  of  the  intestinal  mucous  membrane,  in 
case  they  are  accompanied  by  oxaluria,  have  at  most  only  an  indirect 
causal  relationship.  They  may  determine  oxaluria  by  causing  de- 
ranged digestion  but  cannot  be  considered  as  the  proximate  cause. 

It  must  be  confessed  that  many  of  the  patients  who  are  supposed 
to  be  suffering  from  oxalic  diathesis  or  oxaluria,  have  a  well-marked 
history  of  sexual  excess,  that  spermatozoa  are  not  infrequently  found 
in  decided  quantities  in  the  urine  accompanying  the  oxalate  of  lime, 
and  that  many  of  the  symptoms  which  are  supposed  to  be  the 
direct  result  of  the  excess  of  oxalate  of  lime  may  be  accounted  for  by 
the  debilitating  loss  of  seminal  fluid.  Moreover,  many  of  the  vague 
pains  and  depressed  feelings  can  be  accounted  for  by  the  renal  resent- 
ment of  fixed  oxalate  concretion  or  by  the  passage  of  the  sharp 
irritating  crystals  along  the  sensitive  urinary  passages,  arousing  the 
reflex  excitability  of  the  prostatic  urethra  and  its  innumerable  nerv- 
ous connections. 

Teeatment. 

The  treatment  of  oxaluria  should,  if  it  is  directed  at  all  against 
the  symptom,  be  essentially  prophylactic;  that  is,  our  efforts  should 
be  directed  to  preventing  the  formation  of  that  most  distressing  and 
painful  of  calculi,  the  oxalate  of  lime  or  mulberry  calculus. 

Clinicians  may  differ  as  to  the  concomitant  nervous  symptoms, 
but  they  cannot  permit  themselves  to  overlook  the  necessity  of  pre- 
venting as  far  as  possible  the  formation  of  these  crystals,  which  seem 
more  ready  than  those  of  any  other  urinary  deposit  to  cohere  into 
concretions  either  in  the  renal  tubes  or  pelvis,  or  in  the  bladder. 

To  prevent,  therefore,    the    deposition    of  the    oxalate  of   lime 


640 


FENWICK — DISEASES  OP  THE  URINE. 


crystals  the  diet  should  be  carefully  regulated  although  liberal.  All 
vegetables  and  drugs  containing  oxalates  must  be  avoided.  All  lime 
or  hard  water  should  be  forbidden  and  replaced  by  boiled  or  rain  or 
distilled  water. 

Sugar  should  be  prohibited.  Coffee  and  tea  had  better  be  re- 
placed by  milk.  Alcohol  need  not  be  indulged  in  except  by  those 
who  need  the  tonic  or  astringent  of  the  red  wines  or  bitter  ale. 

Fresh  bracing  air,  such  as  that  at  the  seashore,  should  be  fjro- 
cured.  As  medicine,  nitromuriatic  acid  has  deservedly  enjoyed  a 
great  repute.  It  should  be  combined  with  strychnine  and  the  bitter 
infusions. 

POLYURIA. 

The  secretion  of  an  abnormal  amount  of  urine,  of  low  specific 
gravity,  without  sugar  or  albumin,  and  accompanied  by  extreme  thirst, 
constitutes  the  essential  element  in  the  group  of  symptoms  to  which 
the  name  of  polyuria,  diabetes  insipidus,  polydipsia,  or  diuresis,  has 
been  given.  Polyuria  or  diabetes  insipidus  has  been  classified  since 
the  days  of  Willis  into  groups,  according  to  the  character  of  the  secre- 
tion; thus,  hydruria  included  those  cases  in  which  the  solid  matters 
were  deficient  and  the  aqueous  urine  excessive ;  azoturia,  in  which 
there  was  an  excess  of  urea,  as  well  as  an  abnormal  amount  of  urine. 
Many  agree,  however,  with  Sir  W.  Roberts  that  this  classification  is 
valueless  in  practice.  Polyuria  is  a  symptom  of  extra-renal  disease,  as 
well  as  of  certain  renal  affections.  The  entire  subject,  however,  needs 
careful  reconstruction,  based  upon  the  records  of  cases  in  which 
chemical  examination  of  the  urine  is  exact.  It  is  at  present  prefer- 
able, I  submit,  to  classify  polyuria  clinically  and  without  reference 
to  the  amount  of  urea  present,  and  for  this  purpose  a  distinction 
must  be  drawn  between  a  persistent  excess  of  urine  and  a  transient  ex- 
cess.    The  following  table  roughly  separates  the  diseases  into  groups : 


Persistent 

excess 
of  urine. 


Transient 

excess 
(usually 
diurnal) . 


Low  s.g. 


fNo    sugar,     but    extreme 
thirst ;  urea  increased. 

Albumin  with  casts,  but 
without  pus  or  residual 
urine. 


Low  s.  g. 
clear. 


No  albumin,  but  with  re- 
(_     sidual  urine. 

(a)  Sexual  excess  or  de- 
bility (without  inflam- 
mation) .  (b)  Dietetic 
idiosyncrasy — tea,  beer, 
etc.  (c)  Hypochondri- 
asis, hysteria,  nervous- 
ness. 


y  Diabetes  insipidus. 

r  Chronic     Bright' s     disease, 
such  as  granular   kidney,. 
■{      amyloid     kidney     of    ad- 
I      vanced  scrofulous  or  syphi- 
l^     litic  affections. 

{Back  renal  pressure  from 
ureteral  twist  or  prostatic 
atony  or  direct  renal  irri- 
tation of  prostatic  origin. 


POLYURIA.  641 


DiAEETES  Insipidus.* 


Probably  diabetes  insipidus  is  purely  an  extra-renal  disease,  and 
due  more  to  some  train  of  nervous  disturbances  than  to  any  direct 
renal  irritation.  Sir  W.  Roberts,  who  collected  120  examjjles,  found 
that  out  of  42  cases,  cerebral  diseases  or  blows  on  the  head  were 
credited  in  19  as  being  the  cause  of  the  polyuria.  This  is  probably 
due  to  disturbance  of  the  fourth  ventricle.  In  three  cases  the  af- 
fection was  hereditary.  In  a  large  proportion  of  cases  no  cause  could 
be  assigned  for  the  onset  of  the  symptoms.  In  some  of  the  traumatic 
cases  the  thirst  and  diuresis  appeared  with  great  severity  on  the  day 
of  the  accident,  in  others  they  occurred  later. 

Dr.  Matthews  Duncan  has  related  the  case  of  a  woman  who  had 
received  a  severe  blow  on  the  .back  of  her  head,  and  shortly  after 
observed  a  great  thirst  and  diuresis.  These  symptoms  continued  for 
fourteen  years,  at  the  end  of  which  time  she  came  under  observation. 
The  quantity  of  urine  ranged  from  twenty  to  thirty  pints  daily.  She 
enjoyed  fair  health  and  was  the  mother  of  four  healthy  children. 

Symptoms. — The  quantity  of  urine  is  usually  greater  than  in 
saccharine  diabetes.  Fifteen,  twenty,  and  even  forty  pints  are  fre- 
quently mentioned  as  being  the  daily  amount  excreted.  One  little  girl 
under  Sir  W.  Roberts'  care  passed  rather  more  than  one-third  her  own 
weight  of  urine  daily  for  some  weeks.  The  specific  gravity  is  1.003  to 
1.007.  The  urine  is  limpid,  colorless,  and  contains  an  excess  of  urea. 
The  phosphates  are  sometimes  increased  {vide  Phosphaturia) . 

The  thirst  is  intense  and  insatiable ;  thus  Dr.  Willis'  patient  drank 
two  bucketfuls  daily.  The  urine,  however,  does  not  correspond  to 
the  amount  imbibed,  for  when  fluids  are  curtailed  the  diuresis  con- 
tinues and  dehydration  of  the  tissues  results. 

Fair  health  is  recorded  is  many  cases,  but  besides  the  tormenting 
thirst  there  are  usually  marked  signs  of  constitutional  disturbance. 
The  temper  is  capricious,  the  patient  sleepless,  the  bodily  and  men- 
tal strength  is  diminished,  the  sexual  powers  become  weakened,  the 
skin  is  hot  and  dry ;  there  is  emaciation,  and  lumbar  pains  are  com- 
plained of.     Frequency  of  micturition  is,  of  course,  increased.     The 

*  "Diabetes  insipidus  is  said  to  be  distinguished  from  other  low-speciflc-gravity 
polyurias  by  the  large  amount  of  urea  which  is  excreted.  The  daily  quantity  of  urea 
in  diabetes  insipidus  is  said  to  be  three  or  four  times  the  normal  amount"  (Dickinson, 
"  On  Diabetes,  "  p.  206) .  In  other  forms  of  polyuria  the  amount  of  urea  excreted  is 
below  the  normal  amount ;  the  normal  average  is  500  grains  daily  in  adult  men  be- 
tween tlie  ages  of  twenty  and  forty,  or  three  and  one-half  grains  per  pound  of  the 
weight  of  tlie  body. 
Vol.  I. —41 


642  FENWICK — DISEASES  OF  THE  UEINE. 

patient  usually  succumbs  to  some  intercurrent  disease  of  the  brain  or 
to  phthisis. 

Prognosis. — Cases  are  recorded  of  persons  who  have  been  poly  uric 
from  twenty-four  to  fifty  years.  But  these  are  usually  congenital 
cases ;  the  traumatic  variety  generally  lasts  only  a  few  weeks  or  months. 

Out  of  77  cases  of  all  kinds  collected  by  Roberts,  16  were  re- 
corded as  complete  recoveries,  14  ended  fatally,  and  the  remaining 
47  were  still  in  progress  when  reported,  though  in  some  considerable 
amelioration  had  taken  place.  In  the  16  recoveries  the  duration  of 
the  polyuria  was  comjDaratively  short.* 

Morbid  Anatomy  and  Causation. — Our  knowledge  of  the  morbid 
changes  noticeable  in  diabetes  insiiDidus  is  slight.  In  some  in- 
stances marked  changes  about  the  base  of  the  brain,  such  as  tuber- 
culosis (Roberts,  Dickinson) ,  were  discovered  and  in  one  there  was  a 
sarcomatous  tumor  in  the  region  of  the  sella  turcica  (Fazio).  In 
others,  the  neighborhood  of  the  fourth  ventricle  was  affected,  by 
gumma  in  Ralfe's  case,  by  gliosarcoma  in  a  case  recorded  by  Hosier. 
In  one  case  the  abdominal  sympathetic  was  affected  by  malignant  in- 
vasion. In  most,  visible  changes  had  occurred  in  the  urinary  tract, 
but  it  is  probable  that  these  were  secondary.  Phthisical  changes  as 
a  cause  or  consequence  were  found  in  several.  The  immediate 
anatomical  cause  for  the  polyuria  is  probably  an  impairment  of  the 
vasomotor  nerves  of  the  kidney  permitting  the  rapid  transudation 
of  urine. 

By  what  means  the  disturbance  is  excited,  whether  it  be  due  to 
disease  or  traumatism  of  the  base  of  the  brain,  especially  of  the 
fourth  ventricle  (Bernard),  or  of  other  parts  of  the  nervous  system,  or 
to  disease  or  injury  of  the  solar  plexus,  is  at  present  uncertain.  It 
is  undeniable  that  a  large  proportion  of  the  cases  followed  injuries 
to  the  nervous  centres,  and  in  six  cases  (Roberts)  palpable  disease 
of  the  brain  was  found  after  death.  Probably  polyuria  is  merely  a 
symptom  of  many  nervous  disorders. 

Treatment. — Our  therapeutic  efforts,  in  the  absence  of  specific 
knowledge  of  the  cause  or  causes,  are  directed  against  the  prominent 
symptoms — the  thirst  and  diuresis.  Enforced  abstinence  from  fluids 
has  nearly  always  proved  unsuccessful,  most  distressing,  and  in  one 
case  at  least  positively  harmful,  f    Among  the  remedies  most  strongly 

*  "  Of  47  cases  still  in  progress  when  reported,  the  duration  of  the  disease  was 
mentioned  in  35  [36?]  instances.  Five  had  continued  for  a  year  or  under ;  5  for  be- 
tween one  and  two  years  ;  12  for  between  two  and  six  years  ;  6  for  between  six  and 
twelve  years ;  4  for  between  twelve  and  twenty-four  years ;  and  4  for  between 
twenty -four  and  fifty -nine  years"   (Sir  W.  Roberts,  p.  238). 

f  Thus  in  Dr.  Strange's  case  the  amount  of  fluid  ingested  was  cut  down,  and  in 


POLYURIA.  643 

recommended  is  valerianate  of  zinc.  It  is  administered  in  pills,  in 
gradually  increasing  doses,  until  a  daily  dese  of  twenty  grains  is 
readied  (Rayer).  Good  results  from  the  exhibition  of  belladonna 
and  ergot,  or  ergot  alone,  and  of  dilute  nitromuriatic  acid  in  drachm 
doses,  have  been  obtained,  also  from  the  application  of  the  constant 
galvanic  current  to  the  loins  and  hypochondria  (Seidel,  Kiilz, 
Althaus) . 

Chronic  Bright' s  Disease. 

Contracting  granular  kidney  may  exist  for  a  considerable  time 
and  may  even  be  "  in  a  serious  degree  of  development"  before  the 
patient  is  aware  that  there  is  anything  amiss  with  him.  For  years 
the  appetite  and  digestion  may  remain  unimpaired,  and  health  and 
strength  may  seem  perfect.  Suddenly  the  appetite  fails,  the  patient 
becomes  dyspeptic,  he  is  tortured  with  thirst,  and  passes  a  great 
deal  of  urine,  so  that  he  fears  that  he  is  afflicted  with  diabetes. 
The  urine  is  often  secreted  more  abundantly  at  night.  Thus, 
Professor  Carl  Bartels  relates  an  extreme  instance  of  nocturnal  poly- 
uria, in  which  10^  pints  (6,000  c.c.)  were  passed  between  8  p.m.  and 
8  A.M.  The  urine  had  a  specific  gravity  of  1.004,  and  contained 
albumin.  Bartels  says  (Ziemssen's  "  Cyclopedia,"  Vol.  XY.,  p.  431) : 
"  No  other  patient  of  mine  ever  passed  so  huge  an  amount.  In  only 
one  private  case  could  I  feel  sure  I  had  really  estimated  the  entire 
quantity  of  urine  passed  for  a  whole  month.  This  jjatient  excreted 
on  an  average  111  ounces  (3,350  c.c.)  daily.  The  fact  is  remarkable 
that  the  patients  are  invariably  more  tormented  with  the  desire  to 
pass  water  by  night  than  by  day.  One  of  my  private  patients,  for 
example,  who  throughout  his  day's  work  from  9  a.m.  to  4  p.m.  had 
no  call  to  empty  his  bladder,  was  forced  to  get  up  three  or  four  times 
every  night  to  urinate.  It  appears  that  this  greater  frequency  of  the 
desire  to  micturate  at  night  is  founded  upon  the  more  abundant 
secretion  which  takes  place  at  this  time.  The  diurnal  amount  of 
urine  passed  by  the  above-mentioned  patient  was  collected  for  a 
month,  and  upon  twenty-six  days  out  of  this  month  the  night  urine 
was  separated  from  that  of  the  day.  The  day's  urine,  collected  from 
7  A.M.  to  10  P.M.,  stood  on  an  average  at  1,370  c.c.  (45  oz.),  i.e.,  3  oz. 
per  hour;  while  the  night's  urine,  consisting  of  that  passed  during 
the  nine  night  hours,  presented  an  average  of  2,190  c.c.  (72  oz.),  i.e., 

about  a  week's  time  headache  and  febrile  disturbance  ensued,  weakness  and  anorexia 
being  also  noticed.  Diarrhoea  supervened,  followed  by  vomiting,  drowsiness,  coma, 
and  death.  I  cannot,  however,  accept  this  as  a  true  case  of  diabetes  insipidus  be- 
cause of  the  evidences  of  backward  pressure  on  both  ureters  that  were  discovered 
post  mortem  (Beale's  Archives,   1802,  p.  276,  quoted  by  Roberts) . 


644  FENWICK — DISEASES  OF  THE   UEINE. 

8  oz.  per  hour.  This  patient  was  forced  to  get  up  at  least  four  times 
each  night  to  micturate.  Another  patient  passed  in  ten  successive 
nights  upon  an  average  960  c.c,  i.e.,  32  oz.,  each  night,  and  upon 
the  corresponding  days  only  65  c.c,  i.e.,  21  oz." 

DiEECT  Vesico-Prostatic  Iekitation  and  Obsteuction. 

Any  congestion  of  the  neck  of  the  bladder,  such  as  obtains  in  sex- 
ual excitement,  is  apt,  in  some  people,  to  produce  a  temporarily  in- 
creased flow  of  urine.  When  there  is  a  permanent  source  of  irri- 
tation which  does  not  give  rise  to  other  symptoms,  there  is  often  a 
similar  but  persistent  excess.  Thus  in  the  early  stage  of  tuberculosis 
of  the  prostate,  and  in  commencing  senile  enlargement  of  that  organ, 
the  kidney  is  often  reflexly  excited  to  increased  activity,  and  a 
limpid  polyuria  results.  It  seems  to  me  that  when  this  is  observed 
it  forms  a  significant  prodrome  to  disease  of  that  body.  Again,  back- 
ward pressure  from  any  partial  urinary  obstruction,  as  in  hydrone- 
phrosis or  advanced  prostatic  atony,  produces  the  same  phenomena, 
so  that  polyuria  may  be  a  symptom  of  surgical  urinary  disease.  The 
transient  form  is  sufficientlj^  explained  by  the  table  and  hardly  needs 
further  notice. 

The  treatment  of  this  form  of  polyuria  depends  upon  the  cause ; 
the  reader  is  therefore  referred  to  the  various  articles  which  specially 
deal  with  the  diseases  enumerated. 

CHYLURIA. 

Synonyms. — Galacturia,  chylous  urine. 

Definition. 

A  milky  appearance  of  urine,  due  to  the  admixture  of  chyle,  con- 
stitutes the  symptom  known  as  chyluria.  It  is  an  evidence  of  an  ob- 
structive disease  of  the  lymphatic  trunks. 

The  change  in  the  urine  is  perhaps  the  only  constant  characteristic 
of  the  disease,  for  the  symptomatology  is  never  exactly  the  same 
in  any  two  patients. 

Charactees  op  the  Ueine  in  Chyluria. 

Macroscopy. — The  milky  appearance  of  the  urine  is  due  to  the  es- 
cape into  it  of  the  contents  of  the  lacteals  and  intestinal  absorbents 
through  some  accidental  communication.  Unless  some  renal  degen- 
eration is  also  present,  the  urine  is  normal  except  that  it  contains  a 
large  amount  of  fat  in  a  fine  molecular  condition,  albumin,  and  fibrin. 


CHYLUEIA.  645 

In  some  cases  the  urine  assumes  a  pinkish  color  from  the  pres- 
ence of  colored  corpuscles  like  those  of  blood.  This  is  so  frequent 
and  occasionally  so  abundant  in  certain  cases  as  to  justify  the  use  of 
the  term  hsemato-chyluria  (Osier) . 

Commonly — at  least  in  India — says  Lewis,  the  blood-like  admix- 
ture, when  present,  is  seen  forming  a  shreddy,  adherent  coagulum 
at  the  bottom  of  the  vessel  after  it  has  stood  for  some  time.  Fresh 
chyluric  urine  emits  a  strong  milky  or  whey-like  odor,  which  is  in- 
creased by  warming.  If  the  urine  be  allowed  to  stand,  it  behaves  in 
a  similar  fashion  to  blood ;  it  coagulates  into  a  semi-solid  mass  like 
blanc-mauge,  which  then  gradually  contracts  and  separates  into  clot 
and  a  liquid.  Should  the  clotting  process  take  place  in  the  kidney 
or — as  it  more  often  does — in  the  bladder,  renal  and  vesical  colic 
may  ensue  from  mechanical  obstruction. 

The  amount  of  urine  is  increased,  being  80  to  100  oz.  per  diem, 
but  this  increase  may  be  due  in  some  measure  to  the  addition  of  the 
chyle.  The  specific  gravity  varies  between  1.007  and  1.020.  If  ether 
be  added  the  fat  is  dissolved  and  the  milky  appearance  is  lost. 

But  the  fatty  matter  is  not  constant  in  amount.  It  varies  from 
0.2  to  2  per  cent.  It  is  increased  after  meals.  It  also  changes  with 
the  posture  and  the  amount  of  exercise  taken.  Casein  has  not  been 
discovered.  The  urea  is  not  increased.  If  the  urine  be  heated  or 
nitric  acid  be  added,  albumin  falls. 

It  must  be  recollected,  however,  that  sometimes  the  urine  is  not 
chylous  and  milky,  but  lymphous  and  merely  albuminous ;  it  coagu- 
lates spontaneously  into  a  substance  which  has  been  likened  to  "  size," 
"calf's-foot  jelly,"  or  "currant  jelly,"  a  condition  which  much  re- 
sembles the  fibrinuria  of  Ultzmann  {cf.  Hsematuria) . 

The  chyluric  and  lymphuric  urines  are  derived  from  chyle-bearing 
and  lymph-bearing  channels  respectively,  audit  is  the  "variable  ad- 
mixture of  these  two  fluids  which  has  probably  caused  so  much  de- 
viation from  the  average  which  the  published  researches  of  the  per- 
centage constituents  of  chylous  urine  show.  Thus  Sir  W.  Roberts, 
whose  careful  work  on  the  subject  I  have  freely  consulted,  gives  an 
abstract  of  nine  analyses  of  chylous  urine  by  different  authors,  no  two 
being  alike. 

Microscopy. — The  microscope  reveals  fat  in  a  finely  molecular  con- 
dition, blood  cori)Uscles,  and  often  the  nematoid  entozoon  the  filaria 
sanguinis  hominis.  The  filaria  sanguinis  hominis  may  generally  be 
discovered  in  the  urine  at  any  time  of  the  day,  and  in  the  blood  of 
the  patient  if  draion  at  night  (between  9  p.m.  and  6  a.m.)  .  In  the  urine 
the  parasites  are  quickest  found  by  taking  up  and  teasing  out  gently 
one  of  the  small  clots.     Patrick  Manson  says  a  better  plan  consists 


646  FENWICK — DISEASES  OP  THE  URINE. 

in  breaking  up  the  coagulum  in  tlie  urine  witli  a  glass  rod  as  soon  as 
it  is  formed,  and  tlien  searching  the  sediment  which,  after  an  hour 
or  two,  collects  at  the  bottom  of  the  vessel,  in  the  same  way  as  is 
customary  to  examine  for  "casts."  As  large  a  slide  as  is  practicable 
ought  to  be  examined,  and  a  low  power  employed  in  the  first  in- 
stance, as  it  often  happens  that  the  filarise  are  present  in  very 
small  numbers,  and  may  readily  be  overlooked  if  a  small  quantity 
of  the  sediment  only  is  examined  or  if  a  high  power  is  employed. 

Etiology  and  Pathology. 

There  can  be  no  doubt  that  the  evidence  at  our  command  allows 
of  a  division  of  chyluria  into  parasitic  and  non-parasitic  varieties ; 
and  the  knowledge  that  we  now  possess  of  the  parasitic  form  enables 
us  to  surmise  the  causes  for  the  non-parasitic  group. 

Parasitic  Cases. — To  make  the  etiology  clear  it  is  necessary  to 
give  a  brief  account  of  the  h?ematozoon — the  filaria  sanguinis  homi- 
nis,  which  has  a  definite  causal  relationship  to  chyluria.  For  a 
fuller  review  of  this  microscopic  nematoid  entozoon  the  reader  is  re- 
ferred to  the  article  on  parasites. 

The  explanation  now  generalh^  accepted  for  the  appearance  of  chyle 
in  the  iirine  was  first  put  forward  by  Dr.  Vandyke  Carter  in  1861. 
Dr.  Vandyke  Carter  advocated  the  view  that  a  direct  communication 
existed  between  the  chyle-carrying  vessels  and  the  urinary  tracts. 
This,  which  was  in  1862  a  theory,  is  now  a  certainty,  for  the  parasite 
which  induces  such  widespread  changes  in  the  lymphatic  system 
has  been  discovered,  and  a  multitude  of  observations  have  been  made 
in  recent  years  upon  diseases  allied  to  chyluria,  such  as  lymph 
scrotum,  lymph  hydrocele,  craw-craw,  etc.,  which  prove  that  the 
escape  of  chyle  through  abnormal  channels  is  due  to  some  direct 
communication  between  dilated  lymphatics  and  the  surface.  My 
dissection  of  Dr.  Mackenzie's  patient  (see  below),  and  the  discovery 
of  the  dilated  lymphatics  and  blocked  thoracic  duct,  moreover,  leave 
no  doubt  but  that  the  cause  of  the  appearance  of  chyle  in  the  urine  is 
the  accidental  communication  between  the  chyle-bearing  vessels  and 
some  part  of  the  urinary  tract. 

The  part  played  by  the  parental  loorm  (filaria  sanguinis  hominis) 
and  its  embryo  : 

In  1866  Wucherer,  of  Bahia,  discovered  the  embryo  filarise  in  chyl- 
ous urine,  several  of  them  being  in  active  motion.  In  1870  Dr. 
Lewis,  of  Calcutta,  being  ignorant  of  Wucherer's  discovery,  found  in 
chyluric  urine  numerous  living  nematoid  worms,  and  in  1872  this  in- 
defatigable worker  discovered  the  same  entozoon  in  the  blood  of  a 
Hindoo  and  in  the  blood  of  a  chyluric  patient. 


CHYLURIA.  647 

In  1875,  O'Neill  found  the  embryo  nematodes  in  the  exudate  from 
the  skin  in  a  disease  known  to  the  negroes  of  the  West  Coast  of  Africa 
as  "  craw-craw. "  The  next  step  was  taken  by  Dr.  Bancroft,  of  Bris- 
bane, who  in  1876  detected  filarise  in  the  blood  of  a  little  girl,  aged 
ten,  who  was  suffering  from  chyluria.  Dr.  Roberts,  of  Manchester 
(now  Sir  William  Eoberts) ,  and  Dr.  Cobbold  discovered  in  a  speci- 
men of  this  blood,  which  Dr.  Bancroft  sent  to  him,  a  solitary  and 
empty  egg-shell — a  direct  proof  of  the  belief  already  entertained  that 
the  filaria  was  the  lai-val  stage  of  some  larger  nematoid  worm. 

In  1876  Carter,  of  India,  found  the  parent  worm  in  a  lymphatic 
abscess  and  hydrocele  of  the  spermatic  cord.  Dr.  Bancroft  an- 
nounced the  discovery  of  the  parent  parasite  in  a  letter  to  Dr.  Cob- 
bold,  dated  April  20th,  1877.  It  was  a  dead  female  obtained  on 
December  31st,  1876,  from  a  lymphatic  abscess  of  the  arm.  Later  on 
he  obtained  four  living  females  from  a  chylous  hydrocele.  In  1877 
Dr.  Lewis  discovered  two  living  helminths,  male  and  female,  from 
a  case  of  nsevoid  elephantiasis  of  the  scrotum. 

In  1880  Dr.  Manson,  of  Amoy,  discovered  the  parent  worm,  a 
mature  female,  in  lymph  scrotum.  Dr.  Manson  now  advanced  the 
view  that  the  lymphatics,  more  frequently  the  distal  vessels,  are  the 
chosen  and  natural  habitat  of  the  adult  nematode ;  that  the  female 
lying  in  a  lymphatic  duct  emits  her  young,  which  are  carried  into  the 
lymph  current  to  the  lymphatic  glands,  and  having  a  diameter  about 
equal  to  the  lymph  corpuscles,  aided  by  the  power  afforded  by  their 
own  vigorous  movements,  they  readily  enter  and  traverse  the  gland 
tissue.  Thus  they  pass  gland  after  gland,  and  emerging  into  the  effer- 
ent vessels  are  borne  along  the  stream  until  the  thoracic  duct  is 
reached,  when  they  finally  enter  the  blood  itself  (Mastin,  "Annals  of 
Surgery,"  Vol.  VIII.,  p.  31,  1888). 

Both  Bancroft  and  Manson  suspected  there  was  some  intermediate 
host,  and  Manson  in  1878  discovered  the  embryo  in  the  stomach  of 
the  culex  mosquito.  Subsequently  he  found  that  it  was  the  female 
of  a  particular  species  of  mosquito  which  performed  the  office  of  in- 
termediary host.  Dr.  Manson  demonstrated  that  the  female  of  this 
special  variety,  penetrating  the  skin  of  a  filarial  subject,  gorges  herself 
with  the  blood  of  the  victim  of  her  attention,  and,  as  it  is  usually  at 
night  when  she  makes  the  attack,  with  the  filarise  which  are  then 
circulating  in  the  blood  current  of  this  individual. 

The  mosquito  then  repairs  to  water  to  dei:)osit  her  ova.  Many  of 
the  embryo  nematodes  are  digested,  but  some  are  expelled  with  the 
excreta,  or  having  penetrated  into  and  completed  their  development 
in  the  thoracic  and  abdominal  tissues  of  the  mos(iuito,  bore  through 
its  body  wall  and  escape  as  free  nematodes.    Probably  they  are  swal- 


648  FENWICK — ^DISEASES   OP  THE  URINE. 

lowed  by  the  human  subject  with  the  water,  but  of  this  step  we  have 
no  accurate  knowledge  as  yet.  On  re-entering  the  human  body  the 
parasite  reaches  sexual  maturity  and  locates  in  the  lymphatic  sys- 
tem. Here  probably  conjunction  of  the  sexes  takes  place  and  filarial 
embryos  are  produced  in  vast  numbers. 

Dr.  Manson'sresearches  were  confirmed  by  Dr.  Lewis,  of  Calcutta, 
who  found  four  out  of  eight  mosquitoes  captured  at  random  in  one  of 
the  servant's  houses  contained  specimens  of  embryos.  Dr.  Araugo, 
of  Bahia,  verified  the  presence  of  the  embryos  in  mosquitoes  who  had 
fed  upon  the  blood  of  a  French  priest  afiiicted  with  filaria.  Drs. 
Bancroft,  of  Brisbane,  and  Sonsino,  of  Cairo,  corroborate  these  facts. 

The  parent  worm  produces  either  living  embryos  or  aborts  and 
emits  these  in  an  immature  stage  in  the  shape  of  semi-spherical  ova. 

The  former  are  one  seventy -fifth  of  an  inch  long  and  their  breadth 
is  about  the  diameter  of  a  red  blood  corpuscle.  Their  size  enables 
the  free  embryos  to  penetrate  the  walls  of  the  capillaries,  but  the  un- 
hatched  ova  in  which  the  embryos  lie  coiled  up  are  of  larger  diame- 
ter, and  their  size  renders  their  escape  from  the  finer  capillaries 
impossible.  They  are,  therefore,  arrested  in  the  first  lymphatic 
gland  which  may  be  reached.  Blockage  of  the  gland  ensues,  more 
filarise  accumulate  behind  the  obstruction,  and  a  localized  lymphatic 
congestion  results;  the  process  spreads,  with  consequent  dilatation 
and  varicosity  of  the  lymph  vessels  which  drain  into  that  gland. 

The  greater  the  number  of  glands  thus  affected  the  wider  will  be 
the  area  of  dilated  lymph  channels,  the  highest  expression  of  dam- 
age due  to  obstruction  being  found  when  the  thoracic  duct  is  im- 
peded, as  in  Mackenzie's  case.  Thus,  it  is  only  needed  for  a  prolific 
female,  aborting  or  miscarrying  from  some  as  yet  inexplicable  cause, 
to  expel  her  ova  in  numbers  into  the  lymphatic  circulation,  to  pro- 
duce plugging  more  or  less  complete  of  the  lymphatic  glands  through 
a  limited  or  an  extended  area  according  to  the  location  of  the  worm 
(Mastin) . 

The  blockage  of  the  lymphatic  trunks  may  take  place  in  any  part 
of  the  body,  hence  many  lymphatic  diseases,  which  were  formerly 
considered  separate  and  distinct,  are  now  established  as  being  due  to 
filarial  obstruction. 

Dr.  Bancroft  enumerates  the  following  conditions  among  others 
as  being  probably  associated  with  filarise : 

Chylocele,  varicocele,  elastic  tumors  in  the  axilla  and  groin  (hel- 
minthiasis elastica) ,  lymph  vesicles  bursting  on  the  scrotum  and  ab- ' 
domen,    skin   diseases    (craw-craw),    elephantiasis   of    the   scrotum, 
abscess  of  the  scrotum. 

In  a  remarkable  case  published  by  Sir  William  Koberts  in  1868  a 


CHYLUEIA.  649 

coagulable  cliylo-lymplious  discharge  escaped  from  open  vesicles 
which  had  formed  over  the  surface  of  the  abdomen.  After  death  it 
vs^as  found  that  the  cutis  vera  and  the  subcutaneous  tissue  were  trav- 
ersed by  short  lymphatic  channels  or  lacunae,  from  the  width  of  a 
crow-quill  to  that  of  a  hair— apparently  a  vast  intercommunicating 
lymphatic  mesh. 

The  immediate  cause  for  the  appearance  of  chyle  in  the  urine  is 
the  direct  communication  between  the  varicosed  and  dilated  lacteal 
channels  and  some  part  of  the  urinary  tract,  combined  with  intermit- 
tent or  chronic  obstruction  to  the  thoracic  duct  or  a  large  branch  of 
the  same. 

This  communication  may  take  place  through  the  lymphatics  of 
the  bladder  with  the  interior  of  that  viscus,  as  was  proved  by  Havel- 
burg  in  the  case  a  woman  who  had  lived  in  Brazil  for  fourteen 
years.  It  is  reported  that  the  urethra  of  this  patient  was  so  dilated 
by  the  passage  of  chylous  clots  that  a  catheter  was  easily  inserted 
into  the  ureter,  and,  being  retained  there  for  two  hours,  clear  urine 
flowed  through  it.  This  showed  that  the  entrance  of  chyle  was  due 
to  the  direct  lesion  in  the  bladder.  She  had  also  a  small  patch  of 
elephantiasis  in  the  integument  of  the  epigastric  region.  At  the 
post-mortem  a  large  lymphatic  sac  was  found  on  the  left  side 
extending  from  the  true  pelvis  to  the  kidney.  This  was  full  of  white 
blood-streaked  fluid.  The  left  side  of  the  upper  part  of  the  blad- 
der was  quite  imbedded  in  the  recesses  of  the  sac  referred  to,  and 
when  opened  the  bladder  was  found  to  be  perforated  in  this  situation. 

But  in  two  cases  which  I  had  the  opportunity  of  examining,  the 
orifice  of  communication  was  situated  in  the  upper  part  of  the  urinary 
tract.  The  first,  which  is  known  as  Dr.  Mackenzie's  case,  I  dis- 
sected in  a  somewhat  novel  manner,  after  a  plan  I  had  foUoM^ed  in 
working  with  Professor  Braune,  of  Leipzig,  upon  the  valves  of  minute 
venous  channels  of  the  abdominal  walls.*  I  mention  this  here  as  it 
is,  in  my  opinion,  the  only  sure  method  of  dissecting  such  flimsy 
structures  as  dilated  lymphatic  sacs,  and  believe  with  Sir  W.  Rob- 
erts that  the  failure  to  discover  communications  is  due  to  the  want  of 
deliberate  care  and  of  some  method  of  counteracting  the  collapse  of 
the  thin-walled  sacs  after  death. 

By  means  of  light  clips  with  broad  points  and  a  constant  stream 
of  oil  and  water  faintly  colored  with  blue,  each  section  of  the  vari- 
cosed lymx>hatics  can  be  rendered  tense  for  cleaning,  and  their  inter- 
communicating channels  dissected  out  without  rupture  of  their  walls. 

*  Cf.  Braune  and  Fenwick :  "  Die  Venen  der  vorderen  Rumpfwand  des  Men- 
schen.  "     Leipzig,  1884. 


650  FENWICK — DISEASES  OF  THE  XJEINE. 

In  Dr.  Mackenzie's  case  the  dissection  was  carried  out  piece  by- 
piece,  starting  from  tlie  orifice  of  communication  of  the  thoracic  duct 
with  the  left  internal  jugular  and  subclaviail  veins.  Unfortunately 
circumstances  prevented  me  from  describing  the  dissection,  but  my 
late  colleague.  Dr.  Anderson,  undertook  to  do  so,  partly  from  the 
specimen  and  partly  from  the  drawing  which  had  been  carefully  done 
under  my  direction  by  Mr,  Burgess.  Dr.  Anderson  describes  the 
dissection  as  follows : 

"The  thoracic  duct  commences  in  a  dense  mass  of  lymphatic 
tissue  and  glands  which  extends  from  the  bifurcation  of  the  aorta 
below  to  the  level  of  the  aortic  opening  of  the  diaphragm  above. 
Looked  at  from  behind,  this  mass  occupies  the  whole  of  the  space 
between  the  kidneys,  and  is  continuous  below  with  the  chains  of 
lymphatic  tissue  on  the  iliac  arteries.  The  mass  consists  very 
largely  of  enormous  dilated  lymph  sinuses,  which  can  here  and  there 
be  inflated.  The  receptaculum  chyli  commences  b}^  two  large 
lymph  sinuses  about  the  size  of  a  pencil,  one  from  each  side  of  the 
aorta,  and  is  joined  opposite  the  aortic  opening  of  the  diaphragm  by 
a  third  large  sinus  about  the  same  size.  The  duct  now  ascends, 
sinuous  and  much  pouched,  for  three  to  four  inches,  varying  in 
diameter  from  three-eighths  to  half  an  inch,  pervious  for  the  first 
inch  and  a  half  above  the  aortic  opening  of  the  diaphragm,  then 
filled  with  a  loose  clot  for  an  inch  and  a  half,  after  which  it  is  lost  in 
a  tough,  thick  mass  (query,  inflammatory?).  (The  occluded  point  in 
the  thoracic  duct  when  opened  was  found  to  contain  a  very  long, 
twisted  clot,  tapering  at  the  end.)  About  four  inches  above  this 
point,  when  it  can  again  be  traced,  although  still  involved  in  dense 
tissue,  it  is  now  the  size  of  a  small  crow-quill,  impervious,  and  tend- 
ing to  the  left  side  behind  the  aorta.  At  its  termination  in  the  angle 
between  the  left  •  subclavian  and  internal  jugular  veins  it  passes 
through  a  mass  of  lymphatic  tissue,  is  pervious,  and  about  the  size 
of  a  goose-quill.  As  stated,  the  iliac,  the  lumbar,  and  the  renal 
lymphatics  are  very  much  enlarged,  and  the  enlargement  is  specially 
marked  in  the  left  iliac  and  left  renal  lymphatics.  Scattered  through- 
out the  left  renal  lymphatics  are  numerous  hard,  round  masses,  some 
the  size  of  a  pea,  but  mostly  smaller.  These  masses  manifestly  oc- 
cupy the  lymph  sinuses." 

To  this  I  may  add,  the  calculi  found  in  the  lymphatics  of  the  left 
renal  pelvis  were  the  size  of  small  shot.  They  were  composed  appar- 
ently of  layers  of  fatty  material  and  were  all  adherent  to  the  walls  of 
the  dilated  lymphatics  and  usually  behind  the  atrophic  remains  of 
valves.  They  were,  in  my  opinion,  the  evidence  of  a  slackening 
stream  of  chyle  and  were  analogous  to  the  small  phleboliths  which 


CHYLUEIA.  651 

are  found  m  the  prostatic  plexuses  of  veins,  each  phlebolith  being  situ- 
ated in  tliis  portion  beliind  a  diseased  valve,  and  marking  usually  the 
partial  or  complete  obliteration  of  the  trunklet  in  which  the  phlebo- 
lith  is  found  ("Venous  System  of  the  Bladder  and  Prostate," 
Journal  of  Anatomy  and  Physiology,  1892), 

The  actual  site  of  communication  between  the  lymphatics  of  the 
left  renal  pelvis  and  these  extraordinarily  dilated  intercommunicating 
lymphatic  chambers  was  not  discovered,  probably  because  the  work 
was  suddenly  interrupted,  but  as  there  had  been  a  history  of  left 
renal  colic,  and  as  the  channels  were  not  enlarged  much  beyond  the 
edge  of  the  pelvic  brim,  and  as  the  bladder  surroundings  were  not 
matted  or  thickened,  the  orifice  of  communication  was  probably  in 
the  left  renal  pelvis. 

In  a  post-mortem  examination  of  a  case  of  chyluria,  Dr.  Lewis 
found  vast  numbers  of  filarise  in  the  kidneys.  There  were  also 
"  numerous  translucent  oil-like  tubules  of  a  somewhat  varicose  appear- 
ance running  alongside  the  uriniferous  tubes,  as  if  the  lymphatics  or 
minute  blood-vessels  of  the  part  had  been  plugged. "    (Eoberts,  op.  cit. ) 

Lastly,  I  was  able  to  demonstrate  by  means  of  the  cystoscope  a 
renal  source  in  one  chylurio  patient  under  Mr.  Clement  Lucas,  who 
kindly  permitted  me  to  examine  the  patient  and  relate  the  facts  of  the 
case.  It .  was  apparently  of  non-parasitic  origin  and  occurred  in  a 
woman  aged  twenty-four.*  A  small  swelling  had  been  noticed  at 
birth  in  the  lumbar  region,  but  this  had  since  increased  in  size  to 
that  of  a  child's  head.  When  she  was  seven  years  old  the  urine  be- 
came thick  and  milky.  Associated  with  the  tumor  was  an  extensive 
nsevus  invading  the  posterior  aspect  of  the  thigh.  The  swelling  had 
a  distinct  limit,  and  appeared  to  be  also  nsevoid  in  character.  There 
was  probably  some  communication  between  the  swelling  and  the 
lymphatics  around  the  kidney.  Seen  through  the  cystoscope  the 
bladder  was  healthy,  but  the  surface  was  blurred  with  milky  de- 
posit. Jets  of  milky  fluid  were  distinctly  seen  to  issue  from  the 
right  ureter,  and  to  mix  rajjidly  with  the  surrounding  medium. 

Non-Parasitic  Cases. — In  almost  all  cases  of  chyluria,  Manson 
says,  when  the  parasite  is  properly  looked  for  the  filaria  will  be 
found  in  the  urine  and  usually  in  the  blood  also.  He  thinks  that 
the  absence  of  filarise  does  not  always  indicate  that  the  case  is  not  of 
parasitic  origin,  as  there  may  be  only  one  parent  worm  present,  or 
all  i)resent  may  be  of  the  same  sex,  and  thus  there  are  only  sufiicient 
for  obstruction  and  not  for  the  propagation  of  embryos. 

*The  case  was  shown  at  tbo  Clinical  Society,  April  26th.  Lancet,  p.  886, 
May  4th,  1889. 


652  FENWICK — DISEASES   OF  THE  URINE. 

This  view,  thougli  taken  by  one  who  has  been  foremost  in  eluci- 
dating this  interesting  and  obscure  disease,  is  not  yet  assented  to.  It 
is  thought  by  many  that  the  chyluria  is  in  rare  instances  caused  by 
some  pressure  such  as  that  produced  by  a  tumor,  or  constriction 
formed  of  inflammatory  thickening,  in  or  about  the  walls  of  the  tho- 
racic duct,  but  this  condition  has  apparently  not  been  proved  to  exist. 
Osier  records  a  case  of  chyluria,  which  lasted  thirteen  years,  in  which 
filarise  were  never  found.  Post-mortem  examination  showed  that  the 
abdominal  lymph  vessels  were  perfectly  normal,  that  no  parasites  were 
present  in  any  part  of  the  lymphatic  system,  and  that  the  urinary 
system  was  quite  normal.  He  accordingly  believes  that  there  is  a 
non-parasitic  chyluria,  but  can  offer  no  explanation  of  it. 

DlSTEEBUTION. 

This  disease  occurs  endemically  in  Mauritius,  East  and  West 
Indies,  China,  Brazil,  Cuba,  Bermuda,  and  Australia,  and  in  most 
tropical  or  sub-tropical  climates  to  some  extent,  but  there  are  dis- 
tricts in  these  same  countries  which  enjoy  an  immunity,  similar  to  that 
of  temperate  climates,  which  depends  entirely  upon  the  distribution 
of  the  filaria.  Where  Europeans  have  been  affected  they  have  almost 
invariably  travelled  in  those  countries,  but  a  few  cases  have  been  seen 
in  patients  who  have  never  been  abroad.  Some  of  these  have  been 
explained  by  the  fact  that  the  mosquitoes  may  have  been  brought  to 
our  shores  by  trading-vessels,  or  that  the  varicosity  and  rupture  of 
the  lymphatic  meshes  were  due  to  pressure  by  some  inflammatory  exu- 
dation or  tumor  upon  one  of  the  main  chyle  channels. 

Symptomatology. 

"The  course  of  the  disorder,"  says  Roberts,  "is  marked  by  an 
irregularity  and  capriciousness  which  baffle  explanation."  The  on- 
set may  be  sudden,  following  a  nervous  shock  or  a  fall,  or  after  par- 
turition ;  but  usually  it  appears  spontaneously. 

Once  the  effection  is  established,  the  chylous  urine  may  appear 
intermittently  or  be  continuous.  The  interruptions  are,  I  suspect, 
due  to  temporary  blockages  of  the  minute  openings  into  the  urinary 
channel,  and  the  grounds  for  this  belief  are  the  following : 

1.  The  appearance  of  chylous  calculi  in  Mackenzie's  case  showed 
that  the  stream  through  the  terminal  intercommunicating  channels 
had  slackened  and  stagnated,  and  that  inflammation  had  occurred  to 
block  one  or  more  at  least  of  the  channels  altogether.  By  this  means 
the  flow  would  cease  until  the  back-pressure  had  opened  up  a  fresh 
channel  or  set  of  channels,  which  would  finally  become  thinned  and 


CHYLURIA.  653 

would  burst.  In  those  cases  in  whicli  tlie  intermission  extends  over 
years,  it  is  jjrobable  that  other  channels  are  opened  up  which  allow 
of  the  chyle  finding  its  way  into  the  thoracic  duct  by  a  circuitous 
route  of  absorbents. 

2.  It  will  be  noticed  that  in  two  of  the  post-mortems  recorded, 
Mackenzie's  and  Havelard's,  the  lymphatic  varicosities  extended  along 
the  ureter  from  the  kidney  to  the  bladder,  as  if  the  pressure  which 
first  found  an  outlet  at  the  pelvis  of  the  kidney  was  forced  subse- 
quently along  the  lymphatics  which  accompany  the  ureter  and  its 
surroundings.  An  analogue  to  this  is  the  ordinary  varicocele. 
Pressure  abruptly  checked  in  one  vein  by  a  valve  passes  off  into  an 
adjoining  vessel.* 

The  intermissions  in  the  appearance  of  chylous  urine  are  very 
irregular.  The  chylous  flow  may  cease  for  ten  or  more  years  and  be 
again  renewed.  During  the  remissions  the  urine  regains  its  normal 
character.  Sometimes  the  attacks  assume  a  certain  periodicity. 
Thus  in  one  case  the  urine  was  always  chylous  for  eight  days  previous 
to  menstruation ;  in  another  chyluria  preceded  or  accompanied  attacks 
of  epilepsy  or  erysipelas.  In  Mr.  Pearse's  case  it  occurred  when  the 
patient  was  suckling  her  children  and  ceased  on  her  weaning  them. 

There  are  also  diurnal  variations  having  a  relation  to  meals,  exer- 
cise, rest,  and  posture.  Dr.  Mackenzie  observed  in  his  case  that  al- 
terations in  the  meal-times  produced  changes  in  the  character  of  the 
urine.  Thus  the  day  urine  almost  comjjletely  coagulated  and  con- 
tained a  considerable  amount  of  blood,  while  the  night  urine  did  not 
form  so  large  a  coagulum  and  contained  less  blood,  and  was  much 
more  milky.  An  alteration  of  a  few  hours  in  the  meal-times  caused 
the  characters  of  the  day  and  night  urine  to  approximate,  and  when 
the  habits  of  day  and  night  were  completely  reversed  the  conditions 
of  the  urine  were  similarlj^  reversed. 

Posture. — In  Ackerman's  case  f  normal  urine  was  passed  if  the 
patient  lay  on  his  right  side.  Perhaps  the  opening  in  this  case  was 
into  the  left  renal  pelvis  draining  into  the  prevertebral  lymphatics. 
This  would  expain  the  fact  noticed  that  when  the  patient  stood  up 
the  urine  at  once  became  chylous.  J 

Intercurrent  disease,  such  as  an  attack  of  gout,  carbuncle  or  pneu- 
monia, temporarily  suspends  the  chylous  discharge.  Should  the 
chylous  urine  clot,  renal  or  vesical  colic  is  noticed,  and  if  renal  colic 
is  present  it  is  absolute  evidence  of  a  renal  source. 

*  This  is  well  shown  by  colored  water  injections. 
f  Thcsf;  and  previous  cases  are  quoted  from  Roberts,  op.  cit. 
X  Tliis  sounds  somewhat  similar  to  those  cases  in  which  pus  from  the  antrum 
escapes  only  when  the  patient  is  in  certain  positions. 


654  FENWICK — DISEASES  OF  THE   URINE. 

The  course  of  the  disorder  is  very  irregular,  and  it  may  be  of 
indefinite  duration.  The  general  health  nearly  always  suffers  more 
or  less,  there  being  marked  general  debility,  lassitude,  and  depres- 
sion, and  often  gradual  emaciation.  Beyond  the  chylous  character 
of  the  urine  there  are  generally  no  distinguishing  symptoms,  and  the 
constitutional  results  are  probably  entirely  due  to  the  waste  of  nutri- 
tive material. 

Filaria  in  the  Blood. — Manson,  in  a  systematic  research  at  Amoy, 
found  that  one  in  every  ten  Chinamen  had  filari?e  in  his  blood,  but 
most  of  the  men  were  in  perfect  health.  He  thinks  that  probably  so 
long  as  the  parent  parasite  is  healthy  it  is  innocuous;  should  it, 
however,  die,  it  acts  as  a  foreign  body  and  sets  up  irritation  around  it ; 
this  causes  great  obstruction  of  the  duct  in  which  it  is  lying,  and 
an  abscess  may  result. 

Dr.  Manson  discovered  the  most  remarkable  feature  of  the  entire 
subject  in  noting  that  the  parasite  is  found  only  at  night.  "Un- 
less," he  ssbjs,  "there  is  some  disturbance  such  as  fever,  interfering 
with  the  regular  physiological  rhythm  of  the  body,  filaria  embryos 
invariably  begin  to  appear  in  the  circulation  at  sunset ;  their  num- 
bers gradually  increase  till  midnight;  during  the  early  morning 
their  numbers  become  fewer  by  degrees,  and  by  nine  or  ten  o'clock  in 
the  forenoon  it  is  a  very  rare  thing  to  find  one  in  the  blood."  Dr. 
Cobbold  not  inaptly  designated  the  phenomenon  filarial  periodicity. 
Dr.  Myers  of  Formosa,  Dr.  Eennie,  Dr.  Adams,  and  Dr.  Mackenzie 
not  only  confirmed  this,  but  the  latter  also  acutely  showed  that  by 
making  the  patient  change  his  hours  of  sleeping  and  waking,  thus 
turning  night  into  day,  the  filaria  followed  suit.  The  important  fact 
of  inversion  of  filarial  periodicity  was  thus  established. 

Peognosis. 

Death  generally  ensues  from  intercurrent  disorders.  Phthisis 
has  occurred  in  a  good  many  of  the  cases  reported.  One  case  lived 
fifty  years  with  chyluria,  another  twenty-eight  years,  thus  showing 
the  slight  constitutional  effects  which  may  be  caused.  On  the  other 
hand,  it  is  stated  that  some  patients  in  fair  health,  except  for  the 
chyluria,  have  been  known  to  die  unexpectedly,  from  no  recognized 
acute  disease. 

Treatment. 

Now  that  the  true  pathology  of  the  disease  is  understood,  the 
reason  of  the  hopelessness,  in  most  cases,  of  treatment  is  fully  appre- 
ciated. 


BIBLIOGKAPHY.  655 

Manson  insists  that  the  main  point  is  to  endeavor  to  get  the  rup- 
tured varix,  by  which  the  chyle  is  leaking  into  the  urine,  to  heal; 
and  the  patient  therefore  should  be  kept  as  much  at  rest  as  pos- 
sible, by  which  means  the  ruptured  lymphatic  is  afforded  the  best 
chance  of  healing. 

Simpson,  of  Assam,  reported  four  cases,  in  two  of  which  the 
urine  became  natural  in  ten  days  after  5  gr.  of  gallic  acid  and  from  4 
to  15  minims  of  tincture  of  perchloride  of  iron,  thrice  daily,  and  two 
cases  which  cleared  up  in  fourteen  days  under  perchloride  of  iron 
and  large  doses  of  quinine.  In  one  case,  gallic  acid  and  thymol 
were  used  with  success.  Waters  and  Bence  Jones  gave  one  or  two 
drachms  of  gallic  acid  a  day.  Roberts  speaks  well  of  large  and  sus- 
tained doses  of  iodide  of  potassium. 

In  Guiana,  it  is  stated  (Roberts)  that  a  decoction  of  mangrove 
bark,  RMzophora  racemosa,  has  effected  cures,  and  the  seed  of  the 
Nigella  sativa  has  also  been  lauded  in  India.  Thymol  is  also  advised 
by  Laurie. 

Pressure  has  been  tried  by  Dickinson,  an  abdominal  tourniquet 
being  applied,  and  a  partially  successful  endeavor  to  stop  the  regurgi- 
tation of  chyle  toward  the  lymphatics  has  been  thus  carried  out,  but 
this  can  be  followed  only  by  temporary  relief. 

Dickinson  records  a  case  in  which  chyluria  disappeared  after  an 
injection  of  a  solution  of  perchloride  of  iron  into  the  bladder.  On 
the  whole,  treatment  is  practically  nil,  as  the  parent  worms  cannot  be 
dislodged  from  their  habitat  in  the  large  lymphatic  trunks  of  the  ab- 
domen. 


Bibliography. 

Hcematuria  and  Pyuria. 

1.  Hilton  :  Guy's  Hospital  Report,  vol.  xiii.,  1867,  p.  24. 

2.  Ultzmann  :  Ueber  Hamaturie,  p.  134. 

3.  E.  Hurry  Fenwick  :  Venous  System  of  the  Bladder,  Journal  of  Anatomy  and 
Physiology,  1885,  p.  320. 

4.  Pepper's  System  of  Medicine,  vol.  iv.,  p.  104. 

5.  ChLsmore  :  Journal  of  Genito- Urinary  and  Cutaneous  Diseases,  August,  1893. 

6.  Prout:  Stomach  and  Urinary  Diseases,  London,  1840.— Heematuria  and 
Garden  Rhubarb,  " Medicus,  "  Lancet,  June  28,  1890;  "M.D.,"Dr.  Wm.  O'Neill; 
and  Dr.  Charters  White,  Lancet,  July  5,  1890. —Oxaluria  and  Hsematuria,  Francis 
Boyd,  Lancet,  October  24,  1891. 

7.  Lancet,  .June  13,  1891,  p.  1337. 

8.  Harrison  :  Medical  Press  and  Circular,  p.  651,  .Tune  26,  1890. 

9.  Sir  Thomas  Watson  :  Lectures  on  the  Practice  of  Physic,  vol.  ii.,  718,  1843. 

10.  Transactions  of  the  Pathological  Society  of  London,  vol.  xliv.,  p.  96,  1893. 

11.  E.  Hurry  Fenwick  :   Electric  Illumination  of  the  Bladder,  2d  ed.,  p.  195. 


656  FENWICK — DISEASES   OF  THE  URINE. 

13.  Bowlby  :  Clinical  Society  Transactions,  vol.  xx.,  p.  147. 

13.  Lancet,  1885,  vol.  ii.,  p.  104. 

14.  Schede :  Jahrblicher    der  Hamburger    Staats-Krankenanstalten,   Annals  of 
Surgery,  p.  446,  vol.  xvi.,  1892. 

15.  E.  Hurry  Fenvpick  :  Cardinal  Symptoms  of  Urinary  Disease,  p.  25. 

16.  Jacobson :  Operations  in  Surgery,  2ded.,  704;  Wright's  Medical  Chronicle, 
March,  1887,  p.  463. 

17.  Senator :    Berliner   klinische  Wochenschrift,   No.   1,   1891 ;    and   Jacobson : 
Operations  of  Surgery,  704,  2d  ed. 

18.  Thompson :  Tumors  of   the  Bladder,    1884,   p.   66 ;   Gross :  Diseases  of  the 
Urinary  Organs,  3d  ed.,  p.  146. 

19.  British  Medical  Journal,  1889,  May  4. 

20.  E.  Hurry  Fenwick  :  Electric  Endoscopy,  2d  ed..  Case  40,  p.  157,   1889.     Re- 
corded in  the  British  Medical  Journal,  Sept.  22  and  Oct.  13,  1888. 

21.  Ibid.,  p.  178,  Case  49. 

22.  Prout :  Nature  and  Treatment  of  Urinary  Diseases,  1840,  p.  328. 

23.  Knowsley  Thornton  :  Surgery  of  the  Kidneys,  p.  47. 

24.  Brodeur  :  Affections  du  Rein,  p.  147,  1886. 

25.  Morris  :  Surgical  Diseases  of  the  Kidney,  p.  142. 

26.  Israel :  Deutsche  medicinische  Wochenschrift,  No.  1,  1892. 
26a.  Morgagni :  De  Sedibus,  Epist.  43. 

27.  Lectures  on  Diseases  of  the  Urinary  Organs,  1842,  p.  124. 

28.  Shaw  :  Holmes'  System  of  Surgery,  vol.  iv.,  p.  125. 

29.  Pathological  Society  Transactions,  vol.  xxxvii.,  563,  1886. 

30.  Day  :  Clinical  Society  Transactions,  p.  24,  1893. 

31.  Bloxam  :  British  Medical  Journal,  Nov.  17,  1894,  p.  1112. 
82.  Lancet,  p.  145,  Jan.  17,  1891. 

33.  Dickinson,  W.  Howship  :  Renal  Affections,  vol.  iii.,  p.  668,  1885. 

34.  Annales  de  Gynecologic,  August,  1890. 

Cystinuria. 

Baumann :  Zeitschrift  fiir  physiologische  Chemie,  Bd.  viii. ,  1883,  p.  300; 
Bd.  xii.,  1888,  p.  261;   Bd.  xvi.,  1893,  p.  552. 

Beale,  Lionel  S.  :  See  under  Phosphaturia. 

Bird,  Golding :  Urinary  Deposits,  their  Diagnosis,  Pathology,  and  Therapeu- 
tical Indications.     Fifth  edition.     London,  1859. 

Brieger  :  Zur  Kenntniss  der  Bildung  von  Ptomainen  und  Toxinen  durch  patho- 
gene  Bakterien.  Sitzungsbericht  der  Berliner  Akademie  der  Wissenschaften,  Janu- 
ary, 1889. 

Brieger  und  Frankel :  Untersuchungen  liber  Bacteriengifte.  Berliner  klinische 
Wochenschrift,  pp.  241-246  and  268-271,  1890. 

Czapek,  F.  :  Wiener  medicinische  Presse,  1889,  i. ,  p.  30. 

Dickinson,  W.  Howship  :  On  Renal  and  Urinary  Affections.     London,  1885. 

Ebstein  :  Deutsches  Archiv  fiir  klinische  Medicin,  Bd.  33. 

Gamgee,  Arthur :  Text-book  of  the  Physiological  Chemistry  of  the  Animal 
Body,  vol.  ii. ,  Chemistry  of  Digestion.     London,  1893. 

Guyon :  Progrls  Medical,  No.  10,  1878. 

Loebisch  :  Liebig's  Annalen,  182;  Wiener  medizinische  Jahrbiicher,  1877  p.  31. 

Marcet,  William  :  See  under  Phosphaturia. 

Marowsky :  Deutsches  Archiv  fiir  klinische  Medicin,  Bd.  4,  p.  449. 

Niemann  :  Deutsches  Archiv  fiir  klinische  Medicin,  Bd.  18,  p.  233. 


BIBLIOGEAPHY.  ■  657 

Picchini  e  Conti :  Lo  Sperimentale,  Sept.  15,  1891. 
Prout,  William  :  See  under  Phosphaturia. 

Ealfe,  Charles  Henry  :  A  Practical  Treatise  on  Diseases  of   the  Kidneys  and 
Urinary  Derangements.     London,  1885. 

Scherer :  Archiv  fiir  pathologische  Anatomic,  Bd.  10,  p.  238. 
Southam  :  British  Medical  Journal,  ii. ,  1876,  and  ii. ,  1878. 
Toel :  Annalen  der  Chemie  und  Pharmacie,  Bd.  96,  p.  24. 
Ultzmann :  Medicinische  Presse,  No.  29,  1878. 
Wood  :  Boston  Medical  and  Surgical  Journal,  1878. 

Phosphaturia. 

Bartels :   Diseases  of  the  Kidney,  Ziemssen's  Cyclopaedia,  English  translation, 
vol.  XV.     New  York,  1877. 

Beale,  Lionel  S.  :   Kidney  Diseases,  Urinary  Deposits,  and  Calculous  Disorders. 
Third  edition.     London,  1869. 

Begbie,  James :    Works,  edited  by  Dr.  Duckworth.     New  Sydenham  Society, 
1883. 

Beneke,  F.  W.     See  under  Oxaluria. 

Bird,  Golding  :  See  under  Cystinuria. 

Brieger,  L.  :   Ueber  giftige  Producte  der  Faulnissbacterien.     Berliner  klinische 
Wochenschrift,  p.  209,  1884. 

Capitan,  L.  :  Recherches  experimentales  et  cliniques  sur  les  Albuminuries  transi- 
toires.     Paris,  1883. 

Dickinson  :  See  under  Cystinuria. 

JEbstein :   Diseases  of  the  Kidney,  Ziemssen's  Cyclopaedia,  Englisli  translation, 
vol.  XV.     New  York,  1877. 

Edlefssen  :    Elimination  of  Phosphatic  Acid.     Centralblatt  flir  die  medicinische 
Wissenschaft,  July,  1878. 

Jones,  Bence  :  Lectures  on  Pathology  and  Therapeutics.     London,  1866. 

Klein :   Glomerulo-Nephritis.     Transactions  of  the  Pathological  Society,    vol. 
xviii. 

Marcet,  William  :  An  Experimental  Inquiry  into  the  Nutrition  of  Animal  Tissues. 
London,  1874. 

Neubauer  und  Vogel :   Anleitung  zur  qualitativen  und  quantitativen  Analyse 
des  Hams,  9.  Auflage. 

Parkes,  Edmund  Alexander :   The  Composition  of  Urine  in  Health  and  Disease, 
and  under  the  Action  of  Remedies.     London,  1860. 

Prout,  William :    On  the  Nature  and  Treatment  of  Stomach  and  Urinary  Dis- 
eases.    Fifth  Edition,  London,  1848. 

Senator :  On  Albuminuria.     New  Sydenham  Society  Translation,  1884. 

Tessier  :  Du  Diabete  Phosphatique.     Lyons,  1877. 

,  Trousseau :    Clinical   Lectures.     New  Sydenham    Society  Translation,  vols.  1. 
and  iii. 

Tyson,  James  :  A  Guide  to  the  Practical  Examination  of  the  Urine.     Eighth  edi- 
tion, Philadelphia,  1893. 

Zuelzer  :  Untersuchungen  liber  die  Semiologie  des  Harns.     Berlin,  1894. 

Oxaluria. 

Begbie,  James :    On  Stomach  and  Nervous  Disorders  as   connected  with  the 
Oxalic  Diatlicsis.     Edinburgh  Monthly  Journal  of  Medical  Science,  Aug. ,  1849, 
Vol.  I.— 43 


658  FENWICK— DISEASES  OF  THE  UEESfE. 

Beneke,  F.  W.  :  Zur  Physiologie  und  Pathologic  des  phosphorsauren  und 
oxalsauren  Kalkes.     Gottingen,  1850. 

Zur  Entwicklungsgeschichte  der  Oxaluria.     Gottingen,  1853. 

Cantani,  Arnoldo  :  Oxalurie.     German  translation  by  Hahn.     Berlin,  1880. 

Czapek,  F.  :  Prager  Zeitschrift  f lir  Heilkunde,  1881,  ii. ,  p.  345. 

Dickinson,  W.  H.  :     On  Eenal  and  Urinary  AfEections,  vol.  iii. ,  London,  1885. 

Ebstein  and  Nicolaier ;  Report  of  the  Eighth  German  Congress  for  Internal 
Medicine,  1889. 

Frankel :  Zeitschrift  fiir  klinische  Medicin,  Bd.  2,  p.  672. 

Gaglio,  G.  :  Archiv  filr  experimentelle  Pathologic  und  Pharmakologie,  Bd. 
xxii.,  p.  235,  1886-87. 

Filrbringer :  Deutsches  Archiv  filr  klinische  Medicin,  1876,  18,  p.  143 ;  Bd. 
xviii.,  pp.  142  and  190,  1876. 

Klemperer  :  Berliner  klinische  Wochenschrift,  Bd.  xxxix. ,  p.  864. 

Kobert  und  Kussner :  Virchow's  Archiv,  Bd.  Ixviii.,  p.  209. 

Malfatti,  H.  ;  Zlilzer's  Internationales  Centralblatt,  vol.  i. ,  p.  66. 

Modderman :  Schmidt's  Jahrbiicher,  No.  125,  p.  145. 

Neubauer :  Archiv  fur  wissenschaftliche  Heilkunde,  1858,  p.  1. 

Noorden :  Berliner  klinische  Wochenschrift,  No.  39,  1889,  p.  865. 

Peyer:  Volkmann's  Sammlung  klinischer  Vortriige,  No.  336,  p.  3051. 

Ralfe ;  See  under  Cystinuria. 

Roberts,  William  :  A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  fourth 
edition.     London,  1885, 

Schaffer :  Milnchener  medicinische  Wochenschrift,  No.  23,  p.  391. 

Smoler  :  Prager  Vierteljahrsschrift,  1861,  Bd.  69  and  70, 

Ultzmann :  Wiener  Klinik,  p.  125,  1879. 

Chyluria. 

Ackermann  :  Deutsche  Klinik,  Nos.  23  and  24,  1863. 

Beale,  Lionel  S.  :  See  under  Phosphaturia. 

Begbie,  James  :  Edinburgh  Medical  Journal,  August,  1862. 

Bence- Jones  :  Philosophical  Transactions,  1850,  and  Medico- Chirurgical  Transac- 
tions, vols,  xxxiii.  and  xxxvi. 

Bird,  Golding  :  See  under  Cystinuria. 

Bouchardat :  Annuaire  de  Therapeutique,  p.  200,  1862. 

Bourne :  British  Medical  Journal,  No.  1429,  p.  1050.  1888. 

Carter :  Transactions  of  the  Medical  and  Chirurgical  Society  of  Bombay,  vol. 
vii.,  1861;  Medico -Chirurgical  Transactions,  vol.  xlv.,  p.  209,  1863. 

Cobbold,  T.  Spencer  :  Parasites  ;  a  treatise  on  the  entozoa  of  men  and  animals, 
including  some  account  of  the  ectozoa.     London,  1877. 

Dickinson,  W.  H.  :  Pathological  Society  Transactions,  vol.  xxix.,  p.  391. 

Dutt:  Lancet,  vol.  ii.,  p.  87,  1862. 

Eggel :  Inaugural  Dissertation.     Tiibingen,  1869. 

Elliotson  :  Medical  Times  and  Gazette,  Sept.  19,  1857. 

Ewald,  C.  A.  :  Deutsche  medicinische  Wochenschrift,  Nos.  46  and  48,  1881. 

Fayrer  :  On  the  Relation  of  Filaria  Sanguinis  Hominis  to  the  Endemic  Diseases  of 
India.     Medical  Times  and  Gazette,  i. ,  1879. 

Guiteras :  Philadelphia  Medical  News,  April,  1886 ;  Fortschritte  der  Medicin, 
iv.,  974,  1886. 

Havelburg :  Virchovr's  Archiv,  1883,  91,  p.  365. 

Isaacs  :  American  Journal  of  the  Medical  Sciences,  April,  1860. 


BIBLIOGEAPHY.  659 

Lanceraux:  Gazette  des  Hopitaux,  Ixi.,  630,  1888. 

Lewis  :  On  the  Hsematozoon  in  Human  Blood,  its  relation  to  Chyluria  and  other 
Diseases,  and  the  Pathological  Significance  of  Nematode  Hsematozoa.  Calcutta, 
1874.     Quain's  Dictionary,  article  Chyluria. 

Leuckart,  Rudolf  :  The  Parasites  of  Man,  and  the  diseases  which  proceed  from 
them.     English  Translation,  Edinburgh,  1886. 

Mackenzie,  Stephen  :  Pathological  Transactions,  vol.  xxxii. ,  p.  394.  Lancet, 
ii.,  398,  1881. 

Manson  :  Lancet,  Jan.  12,  1878.  Proceedings  of  the  Linnean  Society,  March  7, 
1878.     On  Filaria  Sanguinis  Hominis,  London,  1883. 

Mastin,  W.  M.  :  On  Filaria  Sanguinis  hominis.*  Annals  of  Surgery,  vol.  viii., 
p.  331,  1888. 

Meissner,  Hermann:  Schmidt's Jahrbilcher,  clxv. ,  289,  1875;  clxxxix.,  81,  1881. 

Myers,  Wykehaip  :  Centralblatt  f  ilr  Bacteriologie  und  Parasitenkunde,  ii. ,  761, 
1887. 

Pearse :  Medico  Chirurgical  Transactions,  vol.  xxiv.,  p.  127. 

Ponfick  :  Berliner  klinische  Wochenschrift,  Oct.  4,  1880. 

Priestley  :  Edinburgh  Medical  Journal,  1856,  p.  945. 

Prout,  William  :  See  under  Phosphaturia. 

Rayer  :  Maladies  des  Reins,  tomeiii. ,  p.  387. 

Scheube;  Festschrift  flir  E.  'Wagner,  p.  242.     Leipzig,  1888, 

Sonsino  :  Medical  Times  and  Gazette,  i. ,  1882. 

Waters:  Medico-Chirurgical  Transactions,  vol.  xlv. ,  p.  209. 

Wucherer :  Gazeta  Medica  da  Bahia,   1868,  p.  99. 


*  One  of  the  completest  bibliographies  of  modern  compilations. 


DISEASES 


OF  THE 


FEMALE  BLADDER  AND  URETHRA. 


BY 

HOWARD  A.  KELLY, 

BALTIMORE,    MD. 


DISEASES  OF  THE  FEMALE  BLADDER 
AND  URETHRA. 


INTRODUCTORY. 


Up  to  the  present  time  diseases  of  tlie  urethra,  bladder,  and  ure- 
ters in  women  have  been  the  most  neglected  field  in  the  whole  range 
of  scientific  medicine. 

From  the  earliest  times  urinary  affections  in  the  male,  although 
the  organs  are  more  inaccessible  and  the  diseases  consequently  more 
difficult  to  treat,  have  commanded  the  painstaking  attention  of  phy- 
sicians and  surgeons.  These  affections  in  the  female  on  the  other 
hand  were  either  passed  over  on  account  of  their  similarity  to  those 
in  the  male,  or  the  most  obvious  facts  only,  such  as  the  comparative 
shortness  of  the  female  urethra,  and  the  accessible  position  of  the 
bladder  and  urethra  in  their  relations  to  the  vagina,  were  pointed  out. 
There  is  a  groundwork  of  reason  in  this  neglect,  for  the  commoner 
urinary  diseases  of  men  are  far  more  apt  to  prove  dangerous  to  life. 

A  further  reason  for  the  present  ignorance  regarding  diseases  of 
the  lower  urinary  tract  in  women  is  the  fact  that  they  have  not  been 
made  the  subject  of  exclusive  study  by  specialists.  Gynecologists,  to 
whom  these  diseases  have  been  relegated  by  common  consent,  have 
with  but  few  exceptions,  counted  on  one  hand,  slighted  these  cases 
as  being  difficult  or  impossible  to  diagnose  and  intractable  to  treat- 
ment. 

It  is,  however,  a  satisfaction  to  be  able  to  say  that  this  neglected 
branch  of  our  art  has  finally  been  rescued  from  its  obscurity  by  the 
methods  which  I  shall  describe  in  this  article.  Diseases  of  the 
bladder,  ureters,  and  kidneys  have  now  been  brought  within  the  easy 
range  of  intelligent  diagnosis,  so  that  without  pain  or  injury  to  the 
patient,  and  without  the  intervention  of  any  lens  or  mirror  or  fluid 
medium,  the  whole  urinary  tract  in  women  may  be  examined  and  its 
diseases  correctly  diagnosed  and  successfully  treated.  Gynecology 
may  now  justly  claim  that  at  a  single  step  this  branch  of  the  specialty 
has  advanced  beyond  the  kindred  branch  in  male  diseases. 


664  KELLY — DISEASES  OP  THE  FEMALE  BLADDER  AND  UEETHEA. 

Anatomy. 

Some  brief  anatomical  and  pliysiological  remarks  concerning  the 
urethra  and  bladder  are  a  necessary  preliminary  to  a  consideration 
of  the  methods  of  examination  and  their  pathological  affections  and 
treatment,  but  it  is  not  my  purpose  to  enter  into  the  minute  anatom- 
ical descriptions,  which  will  be  found  upon  consulting  such  works  as 
Sappey  and  Henle. 

Urethra. 

The  female  urethra  is  from  3  to  4  cm.  (l^to  1^  in.)  long  and  7  mm. 
(i  in.)  wide.  It  is  almost  straight,  with  a  slightly  sigmoid  curve. 
Its  external  orifice  normally  appears  as  a  vertical  slit,  the  section  of 
its  canal  proper  stellate,  while  its  internal  orifice  is  transverse. 

The  urethra  is  lined  by  mucous  membrane  which  in  the  con- 
tracted state  is  thrown  into  numerous  folds.  Many  blood-vessels 
penetrate  the  mucosa  and  the  connective  tissue  immediately  beneath 
it,  forming  a  cavernous  network.  Immediately  outside  the  mucosa 
is  a  layer  of  circular  muscular  fibres,  and  outside  of  these  again 
a  layer  of  longitudinal  fibres.  At  the  neck  of  the  bladder  the  cir- 
cular fibres  are  so  thickened  as  to  form  a  distinct  sphincter  which 
controls  the  retention  of  the  urine.  No  such  sphincter  has  been 
satisfactorily  demonstrated  at  the  external  orifice,  although  Luschka 
contended  that  one  existed.  Analogous  to,  and  connected  with,  the 
sphincter  vagince,  the  mucous  folds  of  the  urethra  form  three  princi- 
pal folds,  one  median  on  the  wall  toward  the  vagina,  and  one  on 
each  side.  In  the  depressions  to  the  right  and  left  of  the  median 
fold  lie  pits  and  glands  arranged  longitudinally  in  groups.  A  dozen 
or  more  of  these  are  found  in  a  group.  Near  the  lower  end  of  the 
urethra  these  depressions  are  never  more  than  little  sacs  in  the  mu- 
cosa lined  with  the  same  epithelium  as  the  mucosa  itself.  Similarly 
placed  near  the  upper  part  of  the  urethra  are  the  acinous  glands. 

Just  within  the  cutaneous  margin  of  the  urethra,  one  can  dis- 
cover on  either  side,  posteriorly,  a  little  orifice  not  quite  a  millimetre 
in  diameter.  Upon  pressing  the  posterior  surface  of  the  urethra  up 
against  the  pubis  sometimes  a  small  drop  of  fluid  may  be  made  to 
exude  from  these  orifices.  If  a  sound  1  mm.  in  diameter  be  intro- 
duced, it  will  be  found  to  enter  from  1^  to  2  or  even  3  cm.  (^  to  li  in.), 
never,  however,  passing  beyond  the  internal  orifice  of  the  urethra. 
The  tract  thus  sounded  runs  parallel  to  the  urethra  on  either  side  and 
is  sometimes  considerably  dilated.  •  These  openings  are  the  orifices 
of  the  "glands,"  discovered  by  Prof.  A.  J.  C.  Skene  and  described 


ANATOMY.  665 

in  the  American  Journal  of  Obstetrics,  April,  1880.  They  are 
entirely  different  from  the  other  small  glands  and  pits  found  in 
groups  throughout  the  urethra.  The  orifices  of  the  urethral  pits  are 
for  the  most  part  wider  than  the  portion  of  the  pits  immediately  be- 
low, while  on  the  contrary  the  orifices  of  these  urethral  tubules  are 
regularly  narrower  than  the  succeeding  portion  of  the  canal.  Care 
must  be  taken  in  sounding  them  not  to  push  the  sound  through  the 
gland  wall,  establishing  a  false  passage.  A  further  difference  be- 
tween these  tubules  and  the  urethral  pits  lies  in  the  fact  that  the 
former  are  regularly  confined  to  the  most  superficial  layers  of  the 
mucosa,  while  the  tubules  enter  the  deeper  layers.  They  are  lined 
with  a  well-vascularized  mucosa,  upon  which  numerous  fine  openings 
are  seen.  These  tubules  attain  their  greatest  development  in  the 
years  of  greatest  sexual  activity.  Not  infrequently  their  orifices  lie 
exposed  to  view  in  multiparse. 

Schueller  found  occasionally  a  third  tubule  in  the  middle  line, 
half-way  between  the  normal  orifices.  Cross  sections  of  these  tubules 
show  the  lumen  to  be  usually  stellate,  or  linear,  and  the  farther  the 
section  is  made  from  the  orifice,  the  more  irregular  is  the  form,  the 
lumen  dividing  itself  into  numerous  depressions  and  folds.  Some  of 
the  higher  sections  show  several  canals  lying  close  together,  demon- 
strating the  fact  that  the  tubules  have  ended  in  a  number  of  blind 
sacs.  The  course  of  the  tubules  is  not  straight.  They  are  lined  with 
mucosa  like  that  of  the  urethra  with  loose  connective  tissue  below  it, 
and  are  abundantly  supplied  with  the  cavernous  vessels.  It  is  not 
probable,  as  has  been  asserted,  that  they  represent  or  have  any- 
thing to  do  with  the  terminal  ends  of  Gartner's  ducts,  which  in  foetal 
life  are  lined  with  cuboidal  ciliated  epithelium. 

One  important  anatomical  peculiarity  of  the  urethra  has,  strange 
to  say,  entirely  escaped  the  notice  of  anatomists  and  clinicians.  If 
a  virginal  vaginal  orifice  be  examined,  taking  care  merely  to  expose 
the  parts  without  separating  them,  the  urethral  orifice  will  be  found 
completely  hidden,  being  covered  by  two  lips,  one  on  either  side,  in 
close  connection  with  the  anterior  part  of  the  hymen.  By  the  ap- 
proximation of  these  lips  the  cutaneous  orifice  forms  a  simple  verti- 
cal line,  from  2  or  3  to  10  mm.  beyond  the  level  of  the  vestibule. 
These  folds  are  connected  with  the  posterior  part  of  the  urethral  ori- 
fice, and  project  up  over  the  anterior  portion  of  the  orifice  with  the 
patient  lying  in  the  dorsal  position.  They  are  sometimes  short  and 
inconsjjicuous,  at  others  long — longer  relatively  to  the  urethral  orifice 
than  are  the  labia  minora  relatively  to  the  vaginal  orifice.  They  are 
most  marked  at  the  period  of  greatest  sexual  activity,  disappearing 
with  age.     They  are  also  wont  to  disajjpear  after  numerous  child- 


666 


KELLY — DISEASES  OF  THE  FEMALE  BLADDER  AND  tTRETHEA. 


births,  being  replaced  by  a  patulous  urethral  orifice,  without  distinct 
labia.  In  cases  where  they  have  been  partially  destroyed  their 
previous  position  is  often  indicated  by  a  line  crossing  the  urethral 
orifice,  giving  it  a  characteristic  cruciform  shape.  These  folds  have  a 
mechanical  function,  and  are  clearly  intended  to  protect  the  mucous 
membrane  of  the  urethra  from  mechanical  injury  and  invasion  by  the 
micro-organisms  so  abundant  in  the  vaginal  secretions. 


Bladder. 

The  female  bladder  occupies  the  cavity  of  the  pelvis  anterior  to 
the  uterus  and  broad  ligaments,  and  above  the  vagina.  It  differs 
decidedly  from  the  male  bladder  in  its  topographical  relations  and 
the  form  it  assumes  upon  expansion. 

Writers  differ  in  their  statements  as  to  the  form  of  the  empty 
bladder.     Berry  Hart,  for  example,  states  that  the  normal  empty 


Fig.  69.— Showing  the  Normal  Position  of  the  Bladder  when  Empty. 

female  bladder  presents  an  oval  form  in  sagittal  section  and  forms 
more  or  less  of  a  continuous  canal  with  the  urethra.  Schultze  states, 
on  the  other  hand,  that  in  its  contracted  condition  the  upper  wall 
comes  to  rest  upon  the  lower  in  such  a  manner  that  the  angle  of 
flexion  lies  at  the  utero-vaginal  junction.  Anteriorly  the  angle  of 
flexion  lies  below  the  top  of  the  symphysis  pubis.  This  gives  the 
bladder  the  characteristic  Y-shape  (the  stem  of  the  T  being  repre- 
sented by  the  urethra)  which  has  become  so  familiar  through  frozen 
sections.  I  am  able  to  verify  both  of  these  observations.  The  blad- 
der in  a  quiescent  state  assumes  the  Y-form,  the  upper  hemisphere 


ANATOMY.  667 

resting  in  tlie  lower  like  one  saucer  within  another.  When  actively 
contracting,  however,  it  assumes  the  ovoid  form. 

As  the  bladder  fills  with  urine,  the  expansion  is  greatest  at  the 
sides,  filling  out  the  pockets  in  front  of  the  broad  ligaments,  but  the 
body  of  the  uterus  which  normally  lies  in  contact  with  it  is  not  ele- 
vated in  proportion  to  the  degree  of  lateral  expansion.  The  form  of 
the  distended  bladder  is  an  ovoid  with  its  long  axis  transverse,  and 
a  deep  depression  in  the  middle,  like  a  pair  of  saddle-bags. 

It  is  only  in  cases  of  extreme  distention  that  the  long  axis  be- 
comes vertical,  in  which  case  the  uterus  is  thrown  into  retroposition 
and  the  bladder  is  brought  in  contact  with  the  rectum  as  in  the  male 
pelvis.  A  close  approximation  to  the  conditions  present  in  the  male 
is  also  brought  about  by  the  operation  for  the  extirpation  of  uterus, 
tubes,  and  ovaries  now  so  frequently  performed. 

In  considering  the  origin  and  course  of  the  various  affections  of 
the  female  bladder  it  is  important  to  bear  in  mind  its  intimate  con- 
nection with  the  vagina,  with  the  anterior  part  of  the  cervix  uteri, 
and  its  relations,  through  the  broad  ligaments  on  either  side,  to  the 
tubes  and  ovaries,  which  become  especially  intimate  when  the  latter 
are  enlarged  and  fixed  by  inflammatory  disease  and  tend  to  push  for- 
ward the  broad  ligaments  so  as  to  encroach  upon  the  anterior  part  of 
the  pelvis.  From  the  connection  thus  established  pelvic  abscesses 
may  be  discharged  through  the  bladder;  dermoid  cysts  have  been 
also  known  to  empty  their  contents  in  this  way,  and  I  have  seen  a 
tubercular  tubo-ovarian  abscess  break  through  and  infect  the  bladder 
mucosa. 

The  importance  of  being  familiar  with  the  peculiar  manner  in 
which  the  bladder  distends  becomes  evident,  when  we  recall  the  fre- 
quency with  which  a  few  years  ago  the  stump  of  a  fibroid  uterus  was 
fastened  in  the  lower  angle  of  an  abdominal  wound,  just  above  the 
symphysis  pubis.  In  these  cases  it  is  at  once  evident  that  all  possi- 
bility of  distention  in  the  median  line  in  an  antero-posterior  or  verti- 
cal direction  is  taken  away.  There  is  also  a  limitation  of  the  dis- 
tention in  the  same  direction  after  suspension  of  the  uterus  to  the 
anterior  abdominal  wall  for  the  correction  of  retroflexion.  In  a  case 
which  appeared  to  be  entirely  normal,  I  have  seen  the  bladder  dis- 
tended by  about  eight  ounces  of  urine  almost  wholly  in  front  of  the 
left  broad  ligament.  The  thickness  of  the  walls  of  the  contracted 
bladder  is  ten  or  more  millimetres;  they  become  thinner  upon 
distention,  being  3  to  4  mm.  thick  when  moderately  distended.  The 
mucous  membrane  in  the  contracted  state  is  thrown  into  innumera- 
ble folds  and  convolutions,  similar  to  those  of  the  brain.  The  epi- 
thelium is  two  layers  deep  and  extremely  elastic. 


668  KELLY — DISEASES  OF  THE  FEMALE'  BLADDER  AND  UEETHRA. 

The  bladder  also  contains  crypts  and  numerous  branched  acinous 
glands  lined  with  cylindrical  epithelium.  The  inner  muscular  layer 
of  the  bladder  is  connected  with  the  mucosa  by  an  extremely  loose 
connective-tissue  layer,  excepting  in  the  neighborhood  of  the  trigo- 
num.  This  muscular  covering  consists  for  the  most  part  of  two  lay- 
ers of  smooth  fibres  of  equal  volume,  the  outer  layer  having  a  more  or 
less  vertical  direction,  while  the  inner  is  principally  horizontal  or 
ring-shaped  (Henle).  Among  the  most  important  anatomical  fea- 
tures of  the  bladder  are  the  ureteral  orifices  shortly  to  be  spoken  of. 

In  investigating  and  attempting  to  record  the  results  of  the  exam- 
ination of  numerous  cases  of  diseases  of  the  bladder  coming  to  my 
clinic,  I  have  found  a  fresh  study  of  the  topographical  relations  from 
a  practical  standpoint  to  be  absolutely  necessary. 

Tcypogrwphy . 

The  female  bladder  distended  with  air  and  inspected  per  ure- 
thram,  by  the  speculum,  as  I  shall  describe  farther  on,  has  more  or 
less  the  form  of  a  hollow  ovoid,  into  which  the  observer  is  peeping 
through  a  hole  in  its  wall ;  by  turning  the  speculum,  it  is  possible  to 
gain  a  view  of  every  jDortion  of  the  inner  mucosa. 

Apart  from  the  stellate  vessels  with  their  bifurcations  and  anasto- 
mosing branches,  the  inner  surface  of  the  bladder  at  first  sight  ap- 
pears singularlj'^  barren  in  landmarks,  and  the  clinical  observer  finds 
it  difficult  either  to  convey  to  others  an  intelligent  idea  of  lesions 
noted,  or  even  to  keep  for  himself  an  accurate  record  of  the  progress 
or  decline  of  local  disease.  The  female  bladder  is,  however,  most 
favorably  situated  for  diagnosis  ])er  speculum,  and  it  presents  certain 
well-defined  landmarks,  so  that  the  lack  of  a  topography  of  its  inter- 
nal surface  ought  no  longer  to  embarrass  the  practitioner. 

I  present  the  following  schema  as  a  preliminary  study,  which  will, 
I  hope,  be  found  sufficient  for  present  practical  needs.  My  topo- 
graphy is  based,  it  will  be  seen,  upon  a  consideration  of :  1.  artificial 
landmarks;  2.  natural  landmarks ;  3.  the  relation  of  the  female  bladder 
to  surrounding  structures. 

Artificial  LandmarJcs. — As  I  have  already  observed,  the  bladder 
under  atmospheric  distention  appears  to  one  peeping  into  it  as  a 
hollow  sphere  or  ovoid.  The  two  points,  the  internal  orifice  and 
that  part  of  the  posterior  wall  which  is  directly  opposite  to  it,  may 
'be  conveniently  referred  to  as  the  principal  "polar  points." 

The  "  posterior  pole"  is  the  point  of  departure  in  all  examinations, 
because  it  is  the  first  portion  of  the  bladder  seen  as  the  light  is  re- 
flected from  the  head  mirror  through  the  speculum  turned  directly 
backward.     Any  disease  detected  in  its  neighborhood  may  be  de- 


ANATOMY,  669 

scribed  as  extending  above  or  below  or  around  it,  or  by  tlie  term 
"  circumpolar.'' 

The  posterior  pole  is  a  point  around  wliicli  inflammatory  lesions 
are  specially  likely  to  be  found ;  it  should  also  be  remembered  that  it 
is  the  part  of  the  bladder  most  liable  to  trauma  from  friction  with 
the  edge  of  the  speculum  carried  too  far  in.  The  circumpolar  area 
may  be  conveniently  considered  as  mapped  out  by  three  circles  de- 
scribed around  the  pole  as  a  centre,  having  radii  respectively  1,  2, 
and  3  cm.  in  length.  It  is  true  that  the  posterior  pole  thus  located 
is  not  a  fixed  point,  but  varies  with  different  degrees  of  distention 
of  the  bladder,  or  with  slight  movements  on  the  part  of  the  specu- 
lum. In  spite  of  this  objection,  however,  the  practical  utility  of  the 
plan  of  registration  proposed  is  greater  than  that  of  any  other  plan, 
and  if  a  point  is  once  fixed  as  the  posterior  pole,  in  any  individual 
case,  and  a  sketch  made  locating  the  patch  of  disease,  the  same 
locality  is  readily  found  on  subsequent  examination,  as  the  point  of 
departure  for  further  measurements.  One  other  fixed  line  in  the 
bladder,  always  readily  accessible  in  determining  localization  of  dis- 
eases, is  an  imaginary  line  produced  by  sagittal  section. 

Affections  situated  about  the  anterior  pole  (ostium  urethras  inter- 
num) are  best  described  as  circumurethral. 

Proceeding  another  step  in  our  differentiation,  we  will  consider 
the  bladder  as  divided  into  an  anterior  and  a, posterior  hemisphere. 
The  convenience  of  this  division  is  especially  apparent  in  describing 
affections  of  the  posterior  part  of  the  bladder.  Thus,  if  we  imagine 
the  posterior  pole  as  a  centre  intersected  at  right  angles  by  vertical 
and  horizontal  lines,  the  posterior  hemisphere  will  be  divided  into 
four  quadrants,  a  right  upper  and  lower  quadrant,  and  a  left  upper  and 
lower  quadrant  (dexter  superior  and  inferior,  q.  d.  s.  and  q.  d.  i., 
and  sinister  superior  and  inferior,  q.  s.  s.  and  q.  s.  i.).  The  position 
of  the  line  in  the  plane  of  the  sagittal  suture  cleaving  the  posterior 
hemisphere  vertically  is  especially  easy  to  determine  by  the  eye, 
thus  keeping  right  and  left  sides  in  the  bladder  sharply  distinct  in 
all  its  parts.  With  these  purely  artificial  aids  it  is  possible  to  locate 
precisely  affections  within  the  areas  defined. 

We  may  conveniently  designate  further  an  upper  concave  surface, 
or  vault,  of  the  bladder,  and  a  floor,  or  base,  as  well  as  right  and  left 
lateral  walk.  These  terms  basal  and  apical,  right  and  left  lateral, 
may  be  reserved  for  affections  located  at  the  more  central  parts  of 
these  areas,  near  imaginary  poles  whose  axes  cross  the  bladder  from 
side  to  side,  and  from  top  to  bottom,  at  right  angles  to  the  first  axis 
described. 

Natural  Landmarks. — In  the  anterior  vesical  hemisphere  there 


670  KELLY — DISEASES   OE  THE  FEMALE  BLADDEK  AND  UKETHEA. 

are  several  striking  natural  points  of  reference.  First  of  all  is  the 
internal  orifice  of  the  urethra  itseH,  with  its  circumurethral  area, 
extending  for  an  arbitrary  distance,  say  from  1  to  2  cm.  on  all  sides. 
That  portion  of  the  bladder  lying  immediately  above  the  urethra  may 
be  designated  as  the  symplmjseal  area. 

Below  the  urethra  and  toward  the  base  of  the  bladder,  on  either 
side,  lie  the  ureteral  orifices,  furnishing  the  most  characteristic  land- 
marks, often  called  into  requisition  in  description,  since  they  are  fre- 
cxuently  the  seat  of  disease. 

In  the  knee-breast  position  the  ureteral  orifices  stand  out  most 
prominently,  each  one  forming  a  little  elevation  which  I  propose  to 
call  the  riglit  and  the  left  mons  ureteris.  The  lower  two  or  three  cen- 
timetres of  each  ureter  forms  a  prominent  ridge,  in  some  cases  pro- 
jecting into  the  bladder;  I  would  call  this  ridge  the  ureteral  fold. 

Between  the  ureters,  the  interureteric  fold  often  forms  a  conspic- 
uous landmark,  whether  traceable  by  its  elevation  or  by  the  injection 
of  its  vessels.  It  represents  the  position  of  the  inter-ureteric  liga- 
ment beneath ;  it  may  also  be  a  jjurely  imaginary  line  drawn  from 
one  ureteral  orifice  to  the  other. 

Three  lines,  one  connecting  the  ureters  and  one  uniting  each  ure- 
ter to  the  internal  urethral  orifice,  together  form  the  urethro-ureteral 
triangle,  or  better  the  vesical  triangle,  or  simply  the  triangle  (tri- 
gonum) ,  situated  at  the  anterior  part  of  the  base  of  the  bladder,  a 
most  convenient  area  for  reference  in  the  description  of  diseases  com- 
ing within  its  limit,  or  immediately  adjacent  to  it. 

"Posterior  to  the  interureteric  fold  or  line"  is  an  expression  fre- 
quently found  convenient  in  the  description  of  affections  of  the  base 
of  the  bladder. 

Relations  to  Surrounding  Structures. — Important  points  of  reference 
also  for  the  urologist  are  those  relating  to  the  fixed  and  movable 
portions  of  the  bladder.  As  the  bladder  becomes  emptied,  the  upper, 
more  movable  portion,  covered  with  peritoneum  and  in  relation  with 
the  supra-vaginal  cervix  posteriorly,  settles  down  into  the  lower  less 
movable  portion,  until  it  comes  to  lie  within  it  as  one  saucer  rests  in 
another. 

During  respiration  the  free  upper  half  of  the  bladder  may  often 
be  seen  moving  on  the  lower  half,  as  if  hinged,  and  the  line  of  de- 
marcation between  them  may  be  distinctly  made  out. 

This  difference  between  mobility  and  relative  immobility  seems 
to  determine  to  some  extent  the  localization  of  the  inflammatory 
affections. 

Certain  other  diseases,  such  as  uterine  fistulse  and  carcinoma, 
affect  by  preference  the  narrow  strip  of  surface  in  the  posterior  hemi- 


METHODS   OF  EXAMENING  THE  FEMALE  UEESfARY  ORGANS.  671 

sphere  in  close  relation  to  the  cervix  uteri,  above  the  line  of  flexion 
just  mentioned. 

Below  this  and  running  out  into  pockets  in  front  of  the  broad  liga- 
ment on  either  side,  and  clearly  developed  as  the  bladder  contracts, 
are  the  right  and  left  vesical  cornuaj  {cornu  vesicce  dextrum  and  cornu 
vesicae  sinistrmn) . 

As  these  cornua  become  evident  by  the  contractions  of  the  blad- 
der, the  posterior  fold  (plica  posterior)  is  seen  to  form  low  down, 
extending  across  the  bladder  from  side  to  side,  while  at  the  same 
time  two  other  folds,  one  on  either  side,  are  observed  running 
around  the  lateral  walls  in  the  direction  of  the  urethra. 

These  three  folds  mark  the  boundary  line  between  the  freer  por- 
tion of  the  bladder  and  the  attached  inferior  portion  and  may  in  the 
future  be  conveniently  spoken  of  as  the  plicce  vesiccdes,  posterior,  sin- 
istra, et  dextra. 

Methods  of  Examining  the  Female  Urinary  Organs. 

The  female  bladder,  urethra,  and  ureters  are  open  to  investigations 
by  three  principal  methods:  (1)  by  the  examination  of  the  secre- 
tions;  (2)  by  palpation;  (3)  by  inspection. 

1.  Examination  of  the  Secretions. — The  methods  employed  in  the 
examination  of  secretions  relate  to  the  various  chemical  changes  in 
the  urine,  such  as  increased  acidity  and  marked  oxaluria,  having 
an  irritating  effect  upon  the  bladder  walls  and  the  ureters,  and 
alkalinity  of  the  urine  with  decomposition  and  the  formation  of 
ammonia  salts  and  deposits  of  phosphates.  The  presence  of  more  or 
less  mucus  in  the  urine  is  also  an  important  evidence  of  the  existence 
of  inflammation.  Blood  is  significant  either  of  disease  of  the  kidneys, 
or  of  some  abrasion  or  neoplasm  within  the  bladder  itself.  Various 
inflammatory  affections  are  caused  by  the  presence  of  gonococci, 
staphylococci,  streptococci,  tubercle  bacilli,  and  the  colon  bacillus. 

Bits  of  tissue  in  the  urine,  such  as  epithelial  cells,  little  pieces  of 
tumors,  etc.,  are  indicative  of  inflammation  and  neoplasms.  These 
considerations,  which  might  be  greatly  amplified,  apply  equally  to 
the  male  urinary  organs,  and  belong  more  to  a  general  than  to  the 
special  consideration  of  the  subject  which  we  have  undertaken. 

2.  Palpation. — Much  valuable  information  can  be  gained  in  dis- 
eases of  the  urethra,  bladder,  and  ureters  by  the  sense  of  touch 
alone.  An  investigation  of  the  parts  with  the  index  finger,  if  the 
tactile  sense  is  not  blunted,  reveals  to  us  a  normal  as  contrasted 
with  a  patulous  urethral  orifice.  In  one  of  my  cases,  at  the  first 
examination  my  assistant  i)as8ed  the  finger  directly  into  the  bladder 


672  KELLY — DISEASES   OF  THE  FEMALE  BLADDEE  AND  UKETHRA. 

without  the  slightest  resistance,  discovering  in  this  way  an  extreme 
relaxation  due  to  coitus  per  urethram.  The  finger  will  also  detect  a 
rolling  out  of  the  urethra,  a  dropping  of  the  bladder,  or  a  pro- 
lapse in  which  the  bladder  forms  part  of  the  sac ;  sensitiveness  of  the 
base  of  the  bladder,  and  more  especially  around  its  neck,  may  also 
be  detected  in  this  way.  About  half-way  up  the  vagina,  and  curving 
out  from  the  base  of  the  bladder  toward  the  posterior  and  lateral 
pelvic  walls,  in  the^  direction  of  the  cervix  uteri,  the  finger  will  detect 
a  flattened  cord-like  body  which  can  be  traced  for  about  10  cm.  (4  in.) 
of  its  course,  losing  itself  behind  the  cervix ;  this  is  the  right  or  left 
ureter. 

If  the  ureter  cannot  be  readily  felt  and  hooked  down  by  the  end 
of  the  finger  in  this  way,  it  will  be  detected  upon  displacing  the  va- 
ginal wall  upward  and  outward  until  the  end  of  the  finger  touches 
the  lateral  wall  of  the  pelvis  just  below  the  superior  strait.  The  fin- 
ger is  then  drawn  downward  and  backward,  stroking  the  pelvic  walls 
and  carefully  estimating  the  size  and  consistency  of  each  structure 
touched.  As  soon  as  the  observer  thinks  he  has  felt  the  ureter,  he 
catches  the  cord  again  with  the  hooked  finger,  draws  it  down  a  little, 
and  slides  the  finger  along  it  toward  the  bladder,  where  it  is  felt 
leaving  the  pelvic  wall,  as  it  passes  toward  the  base.  It  can  be 
caught  again  and  traced  back  until  it  loses  itself  alongside  the  cervix. 
About  8  cm.  (3  in.)  of  the  ureter  can  be  felt  in  this  way.  It  is  never 
hard  like  a  whipcord  or  a  goose-quill,  except  under  pathological 
conditions;  it  is  rather  a  soft,  flat,  yielding  band.  In  some  cases, 
■instead  of  lying  close  to  the  pelvic  wall,  it  is  farther  out  in  the  cellu- 
lar tissue  and  is  then  not  so  easily  felt  with  one  hand. 

In  the  later  months  of  pregnancy,  the  ureter  is  often  felt  with  re- 
markable distinctness  against  the  head  of  the  child.  It  appears  then 
to  be  larger  and  of  firmer  consistency  than  at  other  times. 

The  examiner  must  avoid  mistaking  the  upper  margin  of  the 
levator  ani  muscle,  the  obturator  nerve  or  artery,  or  the  edge  of  the 
obturator  foramen  for  the  ureter. 

That  portion  of  the  ureter  which  lies  in  the  posterior  part  of  the 
pelvis  can  often  be  felt  from  the  rectum.  It  is  particularly  accessible 
to  touch  when  enlarged  by  disease.  The  normal  ureter  can  always 
be  felt  here  when  a  bougie  or  catheter  is  introduced  through  the 
urethra  into  the  ureter  as  far  as  the  brim  of  the  pelvis.  The  land- 
mark in  the  rectum  is  the  internal  iliac  artery,  close  to  which  the 
ureter  lies  on  one  side  or  the  other  during  the  first  part  of  its  course. 
By  these  means,  it  will  be  seen  that  the  whole  of  the  pelvic  portion 
of  the  ureter  is  accessible  to  touch. 

I  have  twice  been  able  to  palpate  with  perfect  distinctness  the 


METHODS  OF  EXAMINING  THE  FEMALE  UBINARY  OEGANS.     673 

normal  ureter  through  the  abdominal  walls,  for  a  short  distance  up- 
ward from  the  brim  of  the  pelvis.  Both  of  these  cases  were  women 
who  had  just  been  confined,  and  the  abdominal  walls  were  lax  and 
the  recti  muscles  separated.  Not  infrequently  a  ureter  enlarged  by 
disease  can  be  detected  as  a  round  cord  through  the  abdominal  walls. 
Almost  always  in  ureteral  inflammatory  disease,  marked  tenderness 
can  be  elicited  on  pressure  at  points  about  3  cm.  (1  in.)  to  the  right 
and  left  of  the  promontory  of  the  sacrum,  which  is  first  located  by 
deep  palpation.  By  a  bimanual  examination,  with  one  or  two  fingers 
in  the  vagina,  and  one  hand  pressing  down  into  the  pelvis  from  above, 
the  ureters  can  always  be  found,  even  when  it  has  not  been  possible 
to  locate  them  with  one  finger  in  the  vagina  as  described.  The  object 
of  the  hand  above  is  twofold,  to  displace  the  ureter  slightly  down- 
ward, making  it  more  accessible  to  the  vaginal  finger,  and  to  keep 
up  an  even  pressure  afl'ording  a  plane  of  resistance  against  which  the 
ureter  can  be  palpated. 

Another  method  of  palpating  the  bladder,  much  in  vogue  in  the 
early  part  of  this  century  and  up  to  within  a  few  years  ago,  is  the 
examination  by  means  of  a  finger  introduced  into  the  bladder  through 
the  dilated  urethra,  or  through  an  incision  in  the  base  of  the  bladder 
from  the  vagina.  The  details  of  this  method  need  not  be  dwelt  upon, 
as  the  perfect  means  of  investigation  now  at  our  command  enable  us 
to  dispense  entirely  with  a  procedure  so  distressing  and  fraught  with 
ill  consequences  to  the  patient.  Many  of  the  victims  of  this  mode  of 
examination  suffered  afterward  from  a  life-long  incontinence. 

Lastly,  a  mode  of  palpation  of  some  value  in  a  preliminary  in- 
vestigation is  the  sense  of  touch  conveyed  by  a  sound  introduced 
into  the  bladder  through  the  urethra,  striking  a  stone  or  coming  in 
contact  with  a  tumor,  or  rugous  surfaces  of  the  bladder.  Hemor- 
rhage thus  easily  excited  is  significant  of  an  inflammation  or  new 
growth. 

3.  Inspection. — But  inspection  is  the  method  which  yields  the 
most  immediate  and  positive  results  in  examining  the  bladder  and 
urethra  for  diagnostic  purposes. 

Inspection  is  able  to  teach  us  much  about  the  bladder  and  ure- 
thra, even  when  confined  to  the  external  parts.  By  inspection  of  the 
external  urethral  orifice,  we  can  determine  its  integrity  or  diseased 
condition,  and  in  the  latter  case  often  see  the  mouths  of  the  urethral 
tubules.  Conditions  of  hypersemia,  inflammation,  and  caruncles  are 
at  once  visiVjle.  Pus  will  sometimes  be  seen  exuding  from  the  ure- 
thral orifice.  A  displacement  of  the  urethra  downward  and  outward 
with  the  vaginal  wall  is  evident.  The  displacement  of  the  bladder 
together  with  the  anterior  vaginal  wall,  known  as  cystocele,  and  the 
Vol.  I.— 43 


674  KELLY — DISEASES   OF  THE  FEMALE  BLADDER  AND  URETHRA. 

more  marked  displacement  of  a  diverticulum  of  tlie  bladder  into  a 
prolapsus  sac,  are  also  easily  determined  by  inspection.  The  long 
ovoid,  over-distended  bladder  pushing  out  tlie  lower  abdominal  wall 
lias  a  characteristic  appearance.  Since  I  propose  to  describe  a  new 
method  of  inspection  which  I  consider  superior  to  all  its  predeces- 
sors and  free  from  their  difficulties  and  dangers,  I  feel  it  necessary  to 
premise  my  description  with  a  brief  consideration  of  the  various  other 
methods  emploj^ed.  I  shall  also  show  that  by  the  same  means  by 
which  we  inspect  the  bladder  and  urethra,  we  are  able  to  treat  their 
affections  topically. 

For  the  inspection  of  the  interior  mucous  surface  of  the  bladder 
some  seven  methods,  more  or  less  widely  differing  from  one  another, 
have  been  proposed. 

Professor  G.  Simon,  of  Heidelberg,  examined  the  parts  of  the 
bladder  which  came  into  contact  with  the  end  of  a  straight  speculum 
and  covered  its  lumen.  By  sliding  the  speculum  about,  different  parts 
of  the  bladder  came  into  view.  He  estimates  the  value  of  endoscopy 
in  these  words :  "  The  value  of  this  procedure  is  much  less  than  by 
palpation,  as  one  can  never  illuminate  more  than  a  small  area  of  the 
bladder,  and  thus  only  by  chance  discover  papillary  enlargements, 
ulcers,  etc. "  As  to  the  discovery  of  the  ureteral  orifics  by  such  a  means, 
he  says,  "  Even  with  the  magnesium  light  we  have  endeavored  in  vain 
to  discover  the  ureteral  orifice.  Endoscopy  is  useful  in  illuminating 
all  points  that  have  been  discovered  by  touch,  and  for  the  illumination 
of  small  areas  is  of  great  seiwice  in  ihe  female,  as  well  as  in  the 
male.'' 

Simon  speaks  of  the  practical  results  of  his  method  of  catheteriz- 
ing  the  ureters  in  these  terms :  "  As  to  the  assurance  of  being  able  to 
introduce  a  sound  or  catheter — in  my  practice  on  corpses  and  the 
seventeen  attempts  on  living  subjects,  I  have  not  succeeded  in  per- 
fecting my  method  to  such  an  extent  that  I  can  feel  confident  of  in- 
troducing the  sound  into  the  ureter  at  every  sitting,  but  I  believe  I 
could  do  it  in  the  majority  of  cases.  I  have  had  no  opportunity  to 
catheterize  the  ureter  in  disease." 

Dr.  Skene,  of  Brooklyn,  examined  the  bladder  through  a  specu- 
lum carrying  a  test-tube.  Inside  of  this  again  a  thin  silver  plate  the 
length  of  the  tube,  and  occupying  about  one-third  of  its  circumfer- 
ence, was  introduced.  At  the  end  of  this  plate  a  mirror  was  attached 
at  an  angle  of  about  100  degrees,  and  at  the  outer  end  a  delicate 
handle  projecting  at  an  obtuse  angle.  By  moving  the  mirror  back- 
ward and  forward  and  turning  it  around  when  the  tube  was  intro- 
duced into  the  bladder  and  urethra,  various  portions  of  the  mucous 
surface  are  brought  into  view,  light  being  thrown  into  the  tube  by  the 


METHODS   OF  EXAMINING  THE  FEMALE   UKINARY   ORGANS.  675 

aid  of  a  concave  mirror.  Skene  sometimes  used  sunlight,  but  on 
account  of  its  uncertainty  x^^^^ferred  gaslight,  taking  his  illumination 
from  a  gas-bracket  having  a  universal  movement. 

Gruenfeld  examined  the  bladder  more  satisfactorily  than  any  of 
his  predecessors,  through  a  simple  straight  metal  tube  blackened  on 
its  inner  surface,  and  with  a  pane  of  glass  fixed  obliquely  at  its  vesi- 
cal extremity.  For  the  illumination,  he  emjoloyed  a  head-mirror 
with  an  electric  light  attached.  He  was  enabled  in  this  way  to  bring 
the  ureter  into  view.  He  was  also  able  to  catheterize  the  ureter  by 
passing  a  small  catheter  through  the  urethra  into  the  bladder  beside 
his  endoscope.  By  inclining  the  endoscoije  to  the  proper  angle, 
which  he  determined  to  be  from  30  to  35  degrees,  the  ureteral  orifice 
came  into  view,  and  the  point  of  the  catheter  which  was  kept  in  front 
of  the  endoscope  was  engaged,  the  endoscope  withdrawn,  and  the 
catheter  pushed  farther  up  into  the  ureter. 

Another  means  of  examination  is  that  of  Nitze,  very  generally 
used  at  present  for  examination  and  catheterization  of  the  ureters  in 
men.  The  source  of  illumination  is  here  a  little  electric  light  at  the 
extremity  of  the  endoscope.  The  view  of  the  inner  surface  of  the 
bladder  distended  with  water  is  transmitted  by  a  telescopic  arrange- 
ment to  the  eye  of  the  observer  at  the  outer  end  of  the  instrument. 
This  complicated,  delicate,  but  useful  instrument  has  been  used 
with  equally  great  advantage  in  examining  the  female  bladder. 

Dr.  Skene,  the  first  American  authority  on  this  subject,  says 
("Treatise  on  Diseases  of  Women,"  New  York,  1889,  page  697): 
"  The  cystoscope  of  Nitze  and  Leiter  is  the  only  instrument  for  thor- 
oughly investigating  the  bladder." 

Eutenberg  made  a  radical  departure  from  both  of  the  methods 
described  by  debasing  a  speculum  with  a  glass  partition  and  a  little 
tube,  running  down  beside  the  speculum,  attached  to  a  rubber  ball  by 
which  he  puffed  the  bladder  full  of  air.  By  means  of  a  reflected 
light  and  a  mirror  attached  to  a  handle,  which  could  be  pushed  in 
and  out  and  rotated,  the  various  parts  of  the  bladder  wall  were  in- 
spected. To  use  this  instrument,  it  is  necessary  to  dilate  the  ure- 
thra almost  to  a  diameter  of  2  cm.  (fin.),  which  can  only  be  done  by 
anaesthetizing  the  patient.  Professor  Winckel  of  Munich  speaks  of 
this  speculum  with  esj^ecial  satisfaction. 

My  own  method  was  first  published  in  the  Johns  Hopkins  Hos- 
pital Bulletin,  for  November,  1893,  and  in  a  longer  and  more  fully 
illustrated  article  in  the  American  Journal  of  Obstetrics  for  January, 
1894.  Its  essential  features  are :  1,  an  atmospheric  dilatation  of  the 
bladder  induced  hy  posture ;  2,  the  introduction  of  a  simple  straight 
speculum  without  fenestra ;  3,   the  examination  of  the  mucous  sur- 


676 


KELLY — DISEASES  OF  THE  FEMALE  BLADDER  AND  URETHRA. 


faces  of  the  bladder  and  urethra  by  means  of  a  light  conveyed  into 
the  bladder. 

This  last  and  newest  method  is  so  important,  promising  as  it  does 
to  clear  up  all  the  difficulties  under  which  we  have  been  laboring 
hitherto  in  the  diagnosis  of  these  affections,  and  to  afford  a  simple 
and  effective  means  of  treatment,  that  I  shall  devote  some  space 
to  a  consideration  of  the  exact  method  of  making  the  examination  and 
its  various  advantages. 

The  following  instruments  are  required:     A   good   light  and  a 


Fig.  70.— Relations  of  the  Pelvic  Structures  in  an  Examination  of  the  Bladder  through  an 
Open  Speculum  by  a  Reflected  Light  (Electric),  under  Atmospheric  Dilatation.  The  speculum 
is  too  short  and  the  bladder  insuiliciently  dilated. 

head-mirror;  a  urethral  dilator;  a  speculum  with  an  obturator  (see 
Fig.  75) ;  a  suction  apparatus  to  empty  the  bladder  completely  (see 
Fig.  79) ;  a  pair  of  long  mouse-tooth  forceps  (see  Fig.  80) ;  a  searcher 
for  discovering  the  ureteral  orifice  (see  Fig.  81) . 

A  general  ansesthetic  is  not  necessary,  unless  the  patient  is  so 
nervous  that  she  will  not  submit  to  any  kind  of  an  examination.  For 
this  reason,  it  is  sometimes  of  advantage  to  use  ether  or  chloroform 


METHODS  OF  EXAMINING  THE   FEMALE  URESfAEY  ORGANS. 


677 


during  tlie  first  examination,  whicli  is  apt  to  be  more  prolonged  than 
the  subsequent  ones.  If  the  urethra  requires  any  dilatation,  a  drop 
of  a  ten-per-cent.  solution  of  cocaine  painted  on  its  external  orifice,  or 
a  piece  of  cotton  wrapped  on  an  applicator  saturated  with  a  four-per- 
cent, solution  and  laid  just  inside  the  orifice,  will  be  sufficient  to 
blunt  the  sensitiveness. 

Immediately  before  examination  the  patient  must  pass  water,  pre- 
ferably in  the  standing  position.  In  spite  of  this  effort  to  empty  the 
bladder  completely,  a  little  residual  urine  almost  always  remains  be- 


Fro.  71. — Attitude  of  Patient  with  Elevated  Pelvis,  Dorsal  Position,  Ready  for  Introduction 
of  Cystoscope  and  Examination  of  the  Bladder  under  Atmospheric  Dilatation. 

hind.     If  the  examination  is  delaj^ed  ten  or  fifteen  minutes,  five  or 
ten  cubic  centimetres  will  be  added. 

The  urethral  orifice  is  now  dilated  by  using  a  conical  dilator  (Fig. 
82,  2) ,  blunt  at  the  jjoint,  72  mm.  long,  and  16  mm.  in  diameter  at  the 
base  and  4  mm,  at  the  point.  This  is  covered  with  vaseline  and,  with 
a  screw-like  movement,  gently  bored  into  the  urethral  orifice.  Two  or 
three  gentle  movements,  holding  the  dilator  poised  between  thumb  and 
forefinger,  will  be  sufficient  to  carry  it  in  as  far  as  the  number  10 
mark  on  the  scale  on  its  side.  This  indicates  a  dilatation  of  1  cm.  in 
diameter,  sufficient  for  all  ordinary  purposes  of  investigation  of  the 


678 


KELLY — DISEASES   OF  THE  FEMALE  BLADDER  AND  URETHRA. 


bladder,  treatment  of  its  surfaces,  and  catheterization  of  the  ureters. 
In  many  cases,  particularly  in  women  who  have  borne  children,  the 
orifice  needs  no  dilatation  to  permit  the  introduction  of  a  speculum 
of  this  size.  The  utmost  damage  done  by  the  dilatation  is  a  slight 
superficial  injury  to  the  mucous  surface  of  the  posterior  margin  of  the 
urethra,  which  never  requires  attention. 

I  wish  to  call  especial  attention  to  the  fact  that  dilatation  of  the 
external  orifice  of  the  urethra  by  a  conical  dilator  alone  is  sufficient 


Fig.  72.— Patient  in  Knee-Breast  Position,  Cystoscope  Introduced.     A  sound  shows  position  of 

anal  orifice. 

for  the  investigation.  A  series  of  dilators  intended  to  dilate  the 
whole  canal  may  be  discarded.  The  speculum  is  a  simple  metal 
cylinder  8  cm.  (3  in.)  long,  of  equal  diameter  from  end  to  end,  funnel- 
shaped  at  its  outer  end,  and  with  a  long  handle  that  can  be  conveni- 
ently grasped  in  the  full  hand,  and  which  is  provided  with  an  obturator. 
The  diameters  of  the  specula  vary  from  5  mm.  up  to  20  mm,  (^  to  | 
in.),  shown  by  Simon  to  be  the  safe  outside  limit.     I  have  all  sizes 


METHODS  OP  EXAMINING  THE  FEMALE  URINARY  ORGANS. 


679 


made  between  these  extremes,  the  successive  numbers  in  the  series 
differing  1  mm.  in  diameter.  They  are  not  conical  like  Simon's  dila- 
tors. The  sizes  most  useful  are  Nos.  8,  10,  and  11.  No.  8  (8  mm. 
in  diameter)  can  be  introduced  into  almost  any  urethra  without  pre- 
liminary dilatation,  as  it  is  scarcely  larger  than  an  ordinary  catheter. 
This  is  the  size  which  will  be  more  frequently  used  by  the  practised 
examiner. 

The  patient  may  be  examined  either  in  the  dorsal  or  knee-breast 
position.     If  in  the  dorsal  position,  she  is  placed  on  the  table  with  legs 


Fig.  73.— Posture  of  the  Patient  During  Cystoscopy,  more  Convenient  to  the  Examiner  and  often 
Yielding  a  Better  Distention  of  the  Bladder  than  with  the  Thighs  Vertical. 

and  thighs  well  flexed,  and  hips  elevated  from  15  to  30  cm.  (6  to  12 
in.)  above  the  level  of  the  table.  If  she  be  a  thin  woman,  when  the 
speculum  is  introduced  in  this  position,  the  air  immediately  rushes 
into  the  bladder,  distending  it.  But  this  simple  process  will  not  suc- 
ceed with  a  fat  woman.  The  most  convenient  and  universally  applic- 
able position  is  the  knee-breast  posture,  with  the  chest  as  close  to 
the  table  as  possible,  and  the  back  well  bent  in.  Frequently  a  more 
satisfactory  x^osture  is  the  knee-breast,  with  the  patient  squatting  a 
little  backward,  so  that  the  buttocks  are  in  a  position  directly  over 
the  calves  of  the  legs  or  the  ankles,  instead  of  being  vertically  over 
the  thighs.     The  si^eculum  is  now  taken  in  hand,  as  shown  in  the 


680 


KELLY — DISEASES  OP  THE  FEMALE  BLADDER  AND  URETHRA. 


illustration  (Fig.  74) ,  and  held 
witli  tlie  thumb  firmly  pressing 
upon  the  handle  of  the  obtura- 
tor. The  urethral  orifice  is  first 
well  cleansed  with  a  boric-acid 
solution.  The  point  of  the  spec- 
ulum is  placed  upon  the  orifice 
and  pushed  up  through  the 
urethra  into  the  bladder  in  a 
direction  describing  a  gentle 
curve  around  the  under  surface 
of  the  symphysis.  As  the 
speculum  is  being  introduced, 
the  vulva  is  held  open  with  the 
other  hand;  in  the  case  of  a 
stout  patient  the  buttocks  are 
held  widely  apart  by  an  assis- 
tant. On  withdrawing  the  ob- 
turator, air  rushes  at  once  into 
the  bladder,  distending  it  with 
an  audible  suction  sound.  If 
it  is  undesirable  or  difficult  to 
keep  the  patient  in  the  knee-breast  position,  she  may  be  gently  turned 
to  the  dorsal  position,  taking  care  to  keep  the  hips  constantly  ele- 


FiG.  74. — Hand  Holding  Cystoscope  in  the  Act  of  In- 
troduction, Keeping  Obturator  Firmly  Pressed  in. 


Fig.  75.— Handle  and  Funnel -Shaped  Orifice  of  Cysto- 
scope. Upper  right-hand  figure  shows  correct 
form  of  lower  end  of  cystoscope  with  obturator; 
left-hand  figure  shows  faulty  collar  is.s.)  around 
obturator,  to  be  avoided. 


METHODS   OF   EXAMINING   THE   FEMALE   URINARY  ORGANS. 


681 


vated  above  the  level  of  the  rest  of  the  abdomen  (Fig.  76) .  The  in- 
testines vihich  have  gravitated  out  of  the  pelvis  will  not  return  at  all, 
or  will  return  but  slowly,  so  long  as  the  hips  are  kept  thus  elevated. 

It  is  well  to  iDlace  a  pledget  of  cotton  or  a  vessel  beneath  the 
mouth  of  the  speculum  to  catch  any  urine  driven  out  by  forcible 
breathing,  coughing,  etc. 

The  examiner  wears  one  of  the  ordinary  head-mirrors  used  by  the 
laryngoscopists,  and  by  its  means  reflects  a  light  from  an  electric  lamp 
resting  on  a  towel  on  the  sacrum  of  the  patient  (if  in  the  knee-breast 


Fig. 


76.— Cystoscopic  Examination  of  Negress  with  Elevated  Pelvis.     Note   electric  light  held 
just  above  the  symphysis,  head  mirror,  and  cystoscope. 


position),  through  the  speculum,  into  the  bladder.  The  illumina- 
tion may  also  be  derived  from  a  small  electric  light  attached  in  front 
of  the  mirror,  or  from  a  mignon  lamp  conveniently  attached  to  the 
mouth  of  the  speculum  so  as  to  throw  its  light  into  the  bladder  with- 
out interfering  with  the  field  of  vision,  as  in  the  Otis  urethroscope. 
I  prefer,  as  the  simplest  and  most  easily  attainable  light,  a  common 
electric  drox>-light,  with  a  short  handle,  connected  with  the  Vjracket  on 
the  wall  by  a  long  cord.  Where  this  is  not  attainable  I  take  with  me 
to  the  place  of  examination  a  small  portable  battery  consisting  of  three 
storage  cells.     This  is  cai)able  of  running  a  mignon  lamp  for  fifteen 


KELLY — DISEASES   OP   THE   FEMALE   BLADDEE   AND   UEETHRA. 

hours  consecutively.  The  only  objection  to  this  form  of  illumination 
is  the  expense  of  the  outfit,  and  its  liability  to  be  out  of  order  just 
when  wanted  for  use.  An  Argand  burner  held  by  an  assistant  may 
be  used,  or  a  lamp  or  candle  in  case  of  necessity.  Dajdight  will  also 
sometimes  be  serviceable,  but  cannot  of  course  be  depended  upon. 

An  important  point  to  be  borne  in  mind,  in  reflecting  the  light 
from  its  source  into  the  bladder,  is  to  make  the  angle  formed  by  the 
pencil  of  light  striking  and  leaving  the  mirror,  as  small  as  possible. 
The  best  arrangement  from  this  standpoint  is  the  little  electric  lamp 
held  immediately  in  front  of  the  reflector  attached  to  the  forehead,  as 
shown  in  the  figures.  The  electric  light  resting  on  the  sacrum  is  for 
this  reason  far  better  than  a  lamp  or  candle,  which  inust  be  held  so 
as  to  make  a  considerable  angle. 

The  first  part  seen  is  about  the  middle  of  the  posterior  wall. 
The  groundwork  of  the  bladder  appears  of  a  dull  whitish  color, 
everywhere  divided  up  by  a  network  of  branching  vessels.  The  inner 
vessels,  almost  like  capillaries,  can  be  traced  to  their  trunks,  and 
these  again  to  larger  trunks  one  or  two  millimetres  in  diameter,  of  a 
dar'k  or  light  red  color  which  seems  to  come  up  to  the  mucous  sur- 
face from  the  deeper  layers  where  the  vessels  lie  hid  from  view. 
Occasionally  an  artery  can  be  distinctly  seen  to  pulsate.  Sometimes 
little  glistening  points  appear  along  the  vessels.  By  elevating  and 
depressing  the  handle  of  the  speculum  and  moving  it  from  side  to 
side,  all  parts  of  the  posterior  hemisphere  are  brought  successively 
into  view.  The  size  of  the  area  viewed  at  any  one  time  depends  upon 
the  calibre  of  the  speculum,  its  closeness  to  the  bladder  wall,  and  the 
distance  of  the  examining  eye  from  the  external  opening.  By  mark- 
edly elevating  the  speculum  the  vault  of  the  bladder  is  seen  with  the 
same  distinctness.  As  a  rule,  the  residual  urine  to  the  amount  of  6 
or  8  c.c.  (li  to  2  drachms)  will  have  to  be  removed  by  the  suction 
apparatus  before  all  parts  are  brought  into  view.  If  the  handle  of 
the  speculum  is  dropped  a  little  the  floor  of  the  bladder  will  come  into 
view.  This  is  more  or  less  in  the  plane  of  the  eye  of  the  observer, 
and  must  be  examined  with  greater  care  to  detect  all  the  peculiari- 
ties of  its  surface.  In  order  to  bring  special  parts  of  the  base  more 
clearly  into  view,  the  speculum  can  be  pushed  until  its  edge  rests 
upon  the  part,  and  then  by  dropping  it  a  few  millimetres  and  ad- 
vancing it  just  a  little,  the  area  in  question  will  be  made  to  lie 
directly  over  the  end  of  the  specuhim,  at  right  angles  to  its  former 
position. 

The  trigonum  is  brought  into  view  by  withdrawing  the  speculum 
until  the  internal  urethral  orifice  just  begins  to  close  over  it,  and  then 
pushing  it  in  a  little  and  dropping  the  handle  slightly.     This  por- 


METHODS  OF  EXAMINING  THE  FEMALE  URINARY  ORGANS. 


683 


tion  of  the  bladder  is  as  a  rule  a  little  more  injected  and  rosy  tlian 
the  rest  of  the  mucosa.  The  inter-ureteric  ligament  is  sometimes 
marked  as  a  distinct  rounded  transverse  fold.  By  turning  the  specu- 
lum to  the  right  or  left  about  thirty  degrees,  with  its  end  projecting 
1  cm.  into  the  bladder,  the  right  and  left  ureteral  orifices  can  be 
brought  successively  into  view.  The  ureteral  orifice  usually  appears 
as  a  little  slit,  about  3  mm.  long,  placed  transversely  with  a  slight 
horseshoe-shaped    elevation    around    it,    open  on   the   inner  side. 


Fig.  77.— Cystoscopic  Examination  of  Black  Woman,  with   Elevated   Pelvis,  Dorsal   Position. 
Introducing  the  searcher  into  the  left  ureteral  orifice. 

Usually,  with  the  woman  in  the  knee-breast  position,  the  ureteral 
orifice  is  found  on  the  inner  side  of  a  decided  eminence,  having  the 
form  of  a  truncated  cone  (mons  ureteris) .  The  ureteral  orifice  may 
at  times  appear  as  a  little  jnt  or  hole  in  the  mucosa,  at  other  times 
as  a  rosette  with  the  opening  in  the  centre.  If  the  observation  is 
continued  for  a  minute  a  little  jet  of  urine  will  be  seen  to  spurt  out  of 
the  ureter  for  two  or  three  seconds.  The  ureter  then  closes  to  be 
oj^ened  by  another  jet  within  the  following  minute.     I  have  repeat- 


684  KELLY — DISEASES  OE  THE  FEMALE  BLADDER  AND  UEETHRA. 

edly  seen  pus  or  blood  escaping  from  one  ureter,  while  clear  urine 
escaped  from  its  fellow. 

The  ability  to  find  the  ureter  readily  is  developed  by  practice. 
An  experienced  observer  will  introduce  the  speculum  and  turn  it  to- 
ward the  side  in  question,  and  with  one  or  two  slight  movements  of 
adjustment,  pushing  it,  withdrawing  it,  or  turning  it  a  little,  will 
have  the  ureteral  orifice  within  the  field  of  vision  within  two  or  three 
seconds. 

Occasionally  the  bladder  presents  some  little  depression  which  the 
examiner  cannot  be  sure  is  not  the  ureteral  orifice.  The  doubt  may 
be  readily  settled  bj"  taking  up  the  searcher,  which  has  a  strongly 
curved  handle,  keeping  it  out  of  the  field  of  vision,  and  introducing 
its  point  into  the  opening.  If  it  is  the  ureter,  the  searcher  will  pass 
readily  3,  4,  or  even  6  or  8  cm.  (1,  1^,  2,  or  3  in.) .  I  have  not  noticed 
any  special  sensitiveness  about  the  ureteral  orifice. 

In  the  virgin,  it  may  be  difficult  to  find  the  ureteral  orifices,  owing 
to  the  fact  that  the  bladder  balloons  out  too  much,  carrying  the  base 
high  up  toward  the  sacrum.  To  gain  even  an  unsatisfactory  view 
under  these  circumstances,  the  observer  has  to  get  his  head  almost 
under  the  patient's  body.  This  difficulty  will  be  overcome  by  taking 
the  precaution  beforehand  to  introduce  a  speculum  into  the  vagina, 
in  order  to  distend  it  with  air.  This  prevents  the  excessive  disten- 
tion of  the  bladder  in  this  direction. 

That  portion  of  the  bladder  which  lies  behind  the  symphysis  may 
be  inspected  by  elevating  the  handle  of  the  speculum  very  decidedly 
and  looking  down  toward  the  anterior  part  of  the  vault. 

Sounding  and  Catheterizing  the  Female  Ureters. 

The  passage  of  a  catheter,  sound,  or  bougie  into  the  ureter  is  as 
easily  accomplished  as  the  inspection  of  its  orifice,  and,  if  gently 
conducted,  is  a  simple,  painless,  and  harmless  procedure.  I  have 
found  it  necessary  under  a  variety  of  conditions,  the  most  important 
of  which  may  be  classified  under  the  following  headings : 

First,  for  the  collection  of  urine  directly  from  the  ureter,  without 
contamination  with  the  bladder,  in  order  to  determine  the  presence  or 
absence  of  renal  disease,  or  of  one  kidney  and  not  of  the  other. 

Second,  to  determine  the  existence  of  ureteral  disease,  such  as 
hydro-ureter  and  pyo-ureter. 

Third,  in  order  to  lay  a  solid  bougie  in  the  ureter,  so  that  it  can 
be  kept  constantly  under  touch  and  recognized  throughout  any  ab- 
dominal or  pelvic  operation  in  which  it  was  in  danger  of  being  cut  or 
tied. 


SOUNDING  AND   CATHETERIZING  THE  FEMAI.E  URETERS. 


685 


For  a  ureteral  catlieter,  I  use  a  simple  metal  tube  about  25  cm. 
(10  in.)  long,  gently  curved  at  its  outer  end,  which  is  held  in  the  hand, 
so  as  not  to  obstruct  the  view  during  its  introduction.  The  end  is 
also  enlarged  a  little,  so  as  to  hold  a  fine  rubber  tube  slipped  over  it 
in  washing  out  the  ureter  and  kidney.  The  ureteral  end  of  the 
catheter  has  a  rounded  point  with  three  or  four  holes  in  it,  and  a 
very  slight  curve  at  the  end. 

To  introduce  the  catheter,  the  ureteral  orifice  is  brought  to  about 
the  centre  of  the  field  of  the  speculum,  and  the  mirror  and  light  are 


Fig.  78. — Catheterizing  the  Ureter.  The  case  illustrated  was  one  of  hydro-ureter  in  which  there 
was  a  stricture  of  the  left  ureter.  The  ureteral  catheter  passed  the  stricture  and  100  c.c.  of 
urine  were  drawn  off  in  less  time  than  3  c.c.  would  be  collected  under  normal  conditions. 


adjusted  so  that  the  head  of  the  observer  is  not  in  the  way  as  he  intro- 
duces the  catheter  into  the  speculum  and  slides  it  on,  until  its  point 
rests  in  the  ureteral  slit.  On  pushing  it  in  a  little,  the  sides  of  the 
opening  separate,  and  it  ap^jears  as  a  hole,  with  the  catheter  lying  in 
one  side  of  it.  The  catheter  must  now  be  pushed  out  gently  toward 
the  side,  stof)ping  at  once  if  the  slightest  resistance  or  obstruction  is 
met.  When  it  has  reached  the  pelvic  wall,  4  or  5  cm.  {1^  to  2  in.)  from 
the  orifice,  it  must  be  firmly  held  while  the  speculum  is  slowly  drawn 
out,  disengaged  from  the  urethra,  and  pulled  over  its  end.  It  is 
usually  necessary  for  an  assistant  to  pull  open  the  buttock  of  the 


686  KELLY — DISEASES   OP  THE  EEMALE  BLADDER  AND  URETHRA. 

side  on  wliicli  the  handle  lies,  to  keep  it  from  making  such  undue 
pressure  upon  the  ureteral  catheter  as  may  injure  the  ureter.  The 
patient  who  has  been  in  the  knee-breast  position  may  now  raise  her- 
self up  on  her  elbows  or  hands,  while  the  urine  is  being  collected  as  it 
flows  from  the  catheter.  A  minute  or  two,  or  more,  often  elapses  be- 
fore the  flow  begins.  It  is  easy  to  tell  whether  the  catheter  is  filling 
by  stopping  up  its  end  with  a  little  drop  of  water,  which  blows  out 
in  the  form  of  a  little  bubble  as  soon  as  there  is  any  movement  within. 
The  urine  escapes  intermittently  by  three,  four,  or  five  drops,  one 
after  the  other,  followed  by  a  pause  of  from  a  few  seconds  to  a  half- 
minute  or  more.  The  average  amount  of  the  flow  should  be  a  half 
cubic  centimetre  H  drachm)  per  minute.  It  is  often  less  than  this, 
but  rarely  more,  unless  there  is  some  disease.  I  have  in  a  number 
of  instances  seen  the  urine  escape  from  the  catheter  in  a  steady 
stream,  but  they  were  all  cases  of  hydro-ureter. 

For  a  prolonged  drainage  of  the  ureter,  or  in  order  to  drain  both 
ureters,  permitting  no  urine  whatever  to  enter  the  bladder,  it  is  nec- 
essary to  introduce  two  short  ureteral  catheters,  with  fine  rubber  tub- 
ing on  the  ends,  in  the  following  manner :  The  catheters  are  about 
6  cm.  long  (2^  in.)  and  2  mm.  (yV  iii-)  in  diameter,  slightly  curved,  and 
with  holes  in  the  end,  like  the  ureteral  catheter  just  described.  The 
outer  end  of  the  catheter  is  a  little  enlarged,  and  over  it  is  passed  a 
piece  of  fine  rubber  tubing  about  15  cm.  (6  in.)  long.  A  stylet  with  a 
strongly  bent  handle  is  coated  with  vaseline  and  introduced  into  the 
catheter  through  the  tube.  This  gives  the  requisite  stiffness  and 
length  for  the  introduction  of  the  catheter  into  the  ureter  after  the 
manner  previously  described.  The  catheter  is  pushed  well  on  until 
its  outer  end  lies  within  the  bladder  1  or  2  cm.  (-^  to  1  in.)  from  the 
ureteral  orifice.  The  stylet  is  now  withdrawn,  and  after  it  the  specu- 
lum, very  slowly,  taking  care  not  to  drag  the  rubber  tubing  with  it. 
The  speculum  is  again  dipped  in  sterilized  vaseline,  and  re-entered 
into  the  bladder,  beside  the  rubber  tube.  The  opposite  ureter  is  now 
exposed  and  catheterized  in  like  manner  and  the  speculum  again 
withdrawn.  The  rubber  tubes  now  lie  in  the  vulvar  cleft  emerging 
from  the  urethra,  conveying  the  urine  from  right  and  left  kidney  into 
separate  vessels.  Care  must  be  taken  to  mark  the  tubes,  distinguish- 
ing right  from  left. 

I  have  also  been  able  to  catheterize  both  ureters  in  this  way  without 
withdrawing  the  speculum,  by  catheterizing  one  first  and  pushing 
several  centimetres  of  its  rubber  tube  into  the  bladder  so  that  it  would 
not  be  pulled  upon,  while  turning  the  speculum  to  the  opposite  side 
to  catheterize  the  other  ureter. 

I  have  had  flexible  bougies  made  2^  mm.  (jV  iu-)  in  diameter  and 


SOUNDING  AND   CATHETERIZING  THE   FEMALE  URETERS. 


687 


40  mm.  (li  in.)  in  lengtH  with  well-rounded  ends.  These  are  kept 
cool  so  as  to  be  stiff  when  wanted  for  use.  If  too  flexible  they  can- 
not be  introduced  into  the  ureter.  The  bougie  is  inserted  into  the 
ureter  by  passing  it  along  the  tube,  which  is  elevated  until  the  end  of 
the  bougie  lies  in  the  urethral  orifice.  The  bougie  is  then  slowly 
pushed  on  2  or  3  cm.  (1  to  li  in.)  at  a  time,  grasping  it  close  to  the 
speculum.  There  is  no  difficulty  in  this  manner  in  carrying  it  all 
the  way  up  to  the  kidney. 


Fig.  79.  —Both  Ureteral  Catheters  Introduced.  Collecting  the  urine  from  right  and  left  side 
separately  in  sterile  tubes.  The  short  metal  catheters  lie  wholly  inside  and  are  connected 
■with  the  test  tubes  hy  fine  rubber  tubing,  as  shown. 


Catheteriztaion  of  the    Ureters  ivitJiout  Elevation  of  the  Pelvis  and 
without  Distention  of  the  Bladder. 

It  is  sometimes  inconvenient  to  elevate  the  hips  of  the  patient, 
especially  if  the  purpose  of  exposing  the  ureteral  orifice  is  only  to 
push  in  a  bougie,  in  order  that  the  ureter  may  be  distinctly  felt 
throughout  a  pelvic  operation.  An  experienced  observer  in  such 
cases  will  usually  be  able  to  locate  the  ureteral  orifice  in  the  follow- 
ing maimer.  The  bladder  is  emptied  as  comi:)letely  as  i)ossible  by  a 
catheter,  the  vesical  speculum  introduced,  and  its  point  turned  in 
the  direction  in  which  the  ureter  is  supposed  to  lie.     The  light  is 


688 


KELLY — DISEASES  OF  THE  FEMALE  BLADDER  AJSID  URETHRA. 


now  directed  into  tlie  bladder  and  its  wall  carefully  inspected,  as  tlie 
speculum  slowly  slides  over  tlie  ureteral  area.  It  is  necessary 
throughout  to  keep  the  speculum  in  close  contact  with  the  mucous 
surface  of  the  bladder  to  prevent  the  urine  from  running  in  and  cov- 
ering the  field  of  vision.  Such  urine  as  does  accumulate  from  time 
to  time  must  be  removed  with  a  suction  apparatus,  or  a  little  pledget 
of  cotton.  I  have  catheterized  ureters  in  this  way  a  number  of  times 
before  doing  a  vaginal  hysterectomy. 


Fig.  80.— Hard -rubber  Bougies  Introduced  High  Up   iuto  Botli  Ureters  to   Facilitate  Hyster- 
ectomy for  Carcinoma  of  the  Cervix. 

A  Method  of  Securing  Urine  from  the  Ureters  without  Catheterization. 


I  desire  now  to  speak  briefly  of  a  novel  development  of  my  method 
of  examining  the  bladder  and  exposing  the  ureteral  orifices,  that  is, 
the  securing  of  urine  direct  from  the  ureter,  without  passing  over  the 
surface  of  the  bladder  and  at  the  same  time  without  introducing  a 
catheter. 

Oftentimes  it  will  be  deemed  inadvisable  to  catheterize  the  ure- 
ters, in  cases  in  which  the  bladder  is  inflamed  or  contains  infectious 
material,  on  account  of  the  danger  of  conveying  the  disease  on  the 
point  of  the  catheter  from  the  bladder  to  the  ureter,  producing  pyo- 
ureter,  pyelitis,  and  pyelonephrosis.  In  these  cases  I  have  been  able 
to  dispense  with  the  catheterization  of  the  ureter  and  gather  a  small 
quantity  of  urine  by  a  very  simple  device. 


SOUNDING  AND   CATHETERIZESfG  THE   FEMALE   URETERS. 


689 


It  is  evident  that  for  the  purpose  of  urinalysis,  obtaining  specific 
gravity,  and  making  microscopic  and  bacteriological  examinations, 
a  few  drops  of  urine  is  as  serviceable  as  a  large  quantity.  When  the 
difference  is  marked  between  the  urine  from  the  two  sides  this  demon- 
stration is  particularly  satisfactory.  Two  methods  may  be  em- 
ployed :  in  one  the  patient  is  placed  in  the  knee-breast  j)Osition,  in 
the  second  she  lies  in  the  dorsal  position  without  elevation  of  the 
hips. 

To  examine  the  patient  in  the  knee-breast  position,  the  only  special 
instrument  needed  is  a  speculum,  a  centimetre  longer  than  the  ordi- 
nary, and  cut  off  obliquely  at  the  end.  The 
ureteral  orifice  is  found  as  described,  and  care- 
fully cleansed  with  a  small  pledget  of  cotton, 
saturated  with  a  warm  boric  acid  solution,  ap- 
plied by  means  of  mouse-tooth  forceps.  The 
orifice  of  the  speculum  is  now  pressed  gently 
up  against  the  bladder  wall  so  as  to  bring  the 
ureteral  orifice  about  in  its  centre.  This  gentle 
pressure  is  kept  up  for  five  or  ten  minutes, 
during  which  time  all  the  urine  escaping  from 
the  ureter  runs  directly  into 
the  speculum  and  down  its 
sides  to  the  outer  edge,  where 
it  is  either  allowed  to  drop  into 
a  small  graduated  glass,  or  is 
taken  u\}  with  a  bit  of  cotton 
and  squeezed  into  a  little  sieve, 
through  which  a  drop  or  two 
of  urine  is  expressed  out  of  the 
cotton  into  the  glass  below. 
This  is  reserved  for  the  exami- 
nation. If  the  other  side  is  to 
be  examined  in  the  same  way, 
the  speculum  must  be  cleansed 
and  re-introduced,  and  the 
urine  collected  after  cleansing 
the  area  around  the  ureter. 
When  the  secretion  of  urine  is 
active — I  have  seen  it  sjmrting 
in  jets — it  will  only  be  neces- 
sary to  hold  the  sj)eculum  up  under  the  ureteral  orifice  without 
touching  the  bladder  wall,  in  order  to  catch  all  that  will  be  required 
for  the  examination. 
Vol.  I.— 44 


Fig.  81.— Evaouator  for  Completely  Emptying  the 
Bladder  of  its  Urine  after  Introducing  the 
Speculum. 


690 


KELLY — DISEASES   OF   THE   FEMALE   BLADDER  AND   UEETHEA. 


To  secure  urine  from  the  patient  in  the  dorsal  2^osition, 
ivitJiout  catheterization,  the  bladder  is  emptied  of  urine 
as  completely  as  possible  witli  tlie  catheter.  Then  the 
ordinary  No.  10  speculum  is  introduced  and  the  ureteral 
orifice  sought  by  sliding  the  speculum  over  the  bladder 
wall,  making  sufficient  pressure  to  keep  out  the  residual 
urine  in  the  bladder.  When  the  orifice  is  found,  the 
speculum  is  pressed  gently  down  on  the  mucosa,  which 
is  carefully  cleansed  with  a  pledget  of  cotton.  The  urine 
then  appears  in  little  jets  at  intervals,  and  is  taken  up 
on  a  small  pledget  of  cotton.  If  the  patient  be  thin, 
and  the  hips  elevated  in  the  dorsal  position,  the  exami- 
nation will  not  be  impeded  by  the  residual  urine  from  the 
bladder  working  in  under  the  edges  of  the  speculum. 


Washing    Out    the 


Ueetees 
Kidneys. 


AND    Pelves    of    the 


A  tc 


.yS 


I  shall  notice  briefly,  as  but  indirectly  pertaining 
to  my  subject,  one  of  the  most  important  developments 
of  this  method  of  investigation.  I  have  found  that  by 
means  of  the  catheter  introduced  into  the  ureter,  con- 
nected bj'  a  long,  delicate  rublier  tube  with  a  funnel,  I 
am  able  with  ease  to  wash  out  the  urinary  tract  up  to 
and  including  the  pehds  of  the  kidney.  The  cases  in 
which  I  have  been  called  upon  to  do  this  have  been  cases 
of  hydro-ureter  with  stricture  at  the  vesical  end  of  the 
ureter,  and  of  pyoureter  with  pyelitis,  also  with  stricture 
at  the  lower  extremity,  and  one  case  of  colon-bacillus 
infection  of  the  right  ureter  and  pelvis.  The  patient  is 
put  in  the  knee-breast  position,  and  the  catheter,  with 
a  short  piece  of  rubber  tubing  attached,  is  filled  with  a 
saline  or  boric  acid  solution,  and  clamped  to  keep  the 
solution  from  running  out.  The  catheter  is  now  intro- 
duced into  the  ureter  at  least  5  or  6  cm.  (2  or  3  in.)  and 
the  speculum  withdrawn.     A  funnel  or  graduated  tube 


■  Fig.  83.— Various  Instruments  Used  in  Ureteral  and  Bladder  Work.     1,  Long 

speculum  cut  obliquely  at  the  end  to  press  up  over  ureteral  orifice  and  catch 
•  the  urine,  with  the  patient  in  the  knee-breast  position,  without  catheteriz- 

ing  the  ureter ;  2,  short  conical  dilator  used  in  enlarging  urethral  orifice  for 
the  introduction  of  the  specuhim ;  3,  short  catheter  with  rubber  tubing  at- 
tached. The  catheter  is  introduced  into  the  ureter  and  left  there  while  collecting  the  urine 
through  the  tube  in  a  receptacle  between  the  thighs;  4,  searcher  for  testing  ureteral  orifices; 
5  o,  upper  and  lower  ends  of  ordinary  ureteral  catheter ;  5  &,  c,  d,  the  upper  ends  of  a  series  of 
dilating  catheters  used  as  bougies  in  dilating  stricture  of  the  ureter. 


SOUNDING  AND  CATHETERIZING  THE  FEMALE  UEETEKS.  691 


For  description  see  foot  of  precedins  page. 


692  KELLY — DISEASES   OE  THE  FEMALE  BLADDER  AND  URETHRA. 

with  a  piece  of  rubber  tubing  about  30  to  40  cm,  (12  to  16  in.)  long, 
having  attached  to  it  a  glass  point  drawn  sufficiently  fine  to  allow  of 
its  introduction  into  the  tube  on  the  catheter,  is  now  filled  with  solu- 
tion and  connected  with  the  catheter.  By  raising  the  funnel  above 
the  level  of  the  body,  the  fluid  is  made  to  flow  into  the  ureter  and 
up  into  the  kidney ;  by  dropping  it  well  below  the  level  of  the  body, 
it  runs  out  again.  In  this  way  the  fluid  can  be  made  to  run  in  and 
out  at  will,  or  fresh  fluid  can  be  used  each  time. 

The  procedure  is  painless  to  the  patient,  who  is  able,  however, 
from  a  little  discomfort  in  the  renal  region  to  guide  the  operator  in 
estimating  when  a  proper  amount  of  distention  has  been  reached. 

When  the  ureter  is  distended  by  pus  or  urine,  this  must  be  with- 
drawn before  running  in  the  fluid. 

One  urgent  word  of  caution  is  necessary  regarding  all  these  ure- 
teral manipulations,  and  it  applies  with  especial  force  to  the  cases  in 
which  infection  already  exists.  It  is  the  constant  necessity  for  pains- 
taking care  in  making  the  manipulations  gentle  throughout.  Any 
roughness  or  pushing  past  obstructions,  or  endeavors  to  push  the 
catheter  up  higher  than  it  will  readily  go,  wiU.  quite  certainly  injure 
the  mucous  coat  of  the  ureter,  and  be  apt  to  be  followed  by  a  sharp 
chill  and  fever,  persisting  from  a  few  hours  to  several  days. 

Examination  of  the  Urethra. 

After  completing  the  examination  of  the  bladder  and  ureters,  the 
urethra  is  examined  throughout  its  whole  extent,  beginning  with  the 
internal  orifice,  and  proceeding  out  to  the  external  one,  as  the  speculum 
is  slowly  withdrawn. 

As  soon  as  the  speculum  leaves  the  lumen  of  the  bladder,  the  in- 
ternal urethral  orifice  is  seen  projecting  over  the  edge  on  all  sides,  in 
the  form  of  a  fine  ring.  Upon  withdrawing  the  speculum  a  little 
farther  the  ring  increases  in  breadth,  contracting,  as  the  speculum 
continues  to  be  withdrawn,  in  a  circular,  oval,  or  trapezoidal  form. 
Just  as  the  lumen  is  about  to  disappear  by  the  meeting  of  the  walls 
on  all  sides,  it  looks  hke  a  small  pinhole,  or  a  little  oval,  2  or  3  mm. 
in  diameter;  it  is  not  a  slit  as  stated  by  so  many  writers. 

Throughout  the  length  of  the  urethra,  the  funnel-shaped  figure 
formed  by  the  mucous  folds  converging  from  the  edges  of  the  specu- 
lum to  the  centre  of  the  canal  is  made  up  of  a  number  of  plicse,  1  or 
2  mm.  in  diameter,  usually  showing  distinct  vessels  running  parallel 
with  the  canal. 

The  color  is  a  deep  rose  or  red,  not  as  intense  as  in  the  male.  At 
both  extremities,  within  a  centimetre  of  the  internal  and  external  os, 


ASEPSIS  IN  EXAMINATIONS.  693 

groups  of  glands  and  tits  are  seen  as  points  or  little  yellowisli  spots 
on  the  mucosa.  Tliey  are  found  more  abundantly  on  the  vaginal 
side  to  the  right  or  left  of  the  median  line.  These  are  the  crypts  or 
pits  and  the  acinous  glands. 

Just  as  the  speculum  is  about  to  escape  entirely  from  the  urethra, 
the  mucous  surface  becomes  pale  and  the  orifices  of  Skene's  tubules 
come  into  view,  appearing  as  darkish  points  about  1  mm.  in  diameter. 

Asepsis  in  Urethral,  Vesical,  and  Ureteral  Examinations. 

Examples  of  general  septic  infection  starting  in  the  lower  urinary 
tract  and  travelling  up,  infecting  bladder,  ureter,  renal  pelvis,  and 
kidney,  and  from  thence  the  system  at  large,  are  sufficiently  abun- 
dant in  medical  literature  to  require  no  demonstration  here  to  prove 
the  possibility  of  such  an  accident.  In  the  male,  the  ascending  cases 
of  gonorrhoea  and  the  cystitis  and  pyelitis  following  the  introduction 
of  a  catheter,  are  the  most  familiar  examples,  while  in  the  female  the 
occasional  outbursts  of  c^^stitis  in  the  gynecological  and  obstetrical 
wards  are  unquestionably  due  to  septic  catheters.  I  remember,  when 
I  was  a  resident  in  a  large  general  hospital,  a  man  with  a  broken 
back  whose  urethra  was  literally  torn  to  pieces  by  the  repeated  intro- 
duction of  a  flexible  catheter  from  which  the  shellac  coating  was  peel- 
ing off  in  thousands  of  little  flinty,  jagged  scales,  all  over  its  surface. 
The  consequence  was  an  intense  purulent  urethritis,  cystitis,  and 
death. 

In  the  same  way  oue  catheter  in  careless  hands  in  an  obstetric 
ward  has  repeatedly  been  the  means  of  infecting  one  patient  after 
another. 

Too  great  care  cannot  therefore  be  taken  in  observing  rigid 
aseptic  rules  throughout  the  manipulations  necessary  for  the  investi- 
gation of  the  urinary  tract. 

The  instruments  must  be  thoroughly  washed  with  hot  water  and 
soap  after  every  investigation,  and  in  inflammatory  and  infected  cases, 
the  dilators,  cystoscopes  with  obturators,  searcher,  catheters,  and 
evacuator,  must  be  boiled  in  a  one-per-cent  soda  solution,  and  then  pre- 
ferably laid  away  between  sterilized  towels.  The  hands  of  the  operator 
and  his  assistants  must  under  no  circumstances  come  directly  into  con- 
tact with  those  portions  of  the  examining  instruments  which  are  intro- 
duced into  the  urethra  and  bladder.  There  is  no  necessity  for  man- 
ual touching  of  the  end  of  the  cystoscope,  the  searcher,  the  ureteral 
catheter,  or  the  little  sterilized  pledgets  of  cotton  with  which  the  resid- 
ual urine  is  taken  out  of  the  bladder. 

The  urethral  orifice  must  always  be  carefully  cleansed  before 


694  KELLY — DISEASES   OF  THE  FEMALE  BLADDEE  AND  UEETHRA. 

a  speculum  is  introduced,  and  if  the  case  is  one  of  gonorrhoeal  infec- 
tion it  will  be  safer  first  to  empty  Skene's  glands,  removing  any  pus 
they  may  contain.  If  there  is  any  acute  inflammatory  trouble  in  the 
urethra  there  will  be  some  danger  of  carrying  up  septic  material  into 
the  bladder  in  pushing  in  the  speculum.  This  ought,  therefore,  not 
to  be  done  without  first  washing  out  the  urethra  with  a  short  catheter 
so  constructed  that  the  water  passing  out  at  the  point  is  directed  back- 
ward into  a  tube  a  short  distance  behind  it  and  thus  allowed  to  es- 
cape. If  there  is  any  inflammatory  trouble  in  the  bladder  the  ureteral 
orifice  ought  first  to  be  wiped  off  with  a  saturated  boric  acid  solution 
before  passing  in  the  ureteral  catheter. 

In  severe  catarrhal  diseases  of  the  bladder  catheters  should  not  be 
left  in  the  ureters  to  drain  off  the  urine  for  any  considerable  time 
unless  an  urgent  necessity  exists. 

Estimate  of  the  Value  of  this  Method  of  Examination. — The  pro- 
cedure described  above  presents  many  points  of  advantage  over  other 
means  of  examining  these  organs.  In  the  first  place,  we  are  enabled, 
by  means  of  a  speculum  8  to  10  mm.  in  diameter,  to  examine  all 
parts  of  the  bladder  and  ureteral  orifices  without  anaesthesia,  with- 
out pain,  and  without  injury  to  the  urethra. 

This  method  is  analogous  to  the  investigation  of  the  posterior 
pharynx,  with  a  reflected  light  and  tongue  depressor,  and  quite  as 
simple.  It  is  more  direct  than  the  examination  of  the  larynx  or  the 
eye.  It  has,  however,  much  in  common  with  ophthalmoscopy,  being 
the  examination  of  the  inner  surface  of  a  spherical  body  through  a 
circular  opening  in  one  of  its  sides.  It  has  a  material  advantage 
over  ophthalmoscopy  in  that  we  are  able  to  see  all  parts  of  the 
sphere  equally  well,  even  those  lying  anteriorly  near  the  opening.  We 
have  also  here  the  further  advantage  of  being  able  to  investigate  the 
condition  of  distant  organs  such  as  the  ureters  and  kidneys.  An 
analogous  condition  in  eye  diseases  would  be  the  power  to  examine 
the  optic  tracts  in  the  brain  and  draw  important  conclusions  as  to 
brain  disease. 

We  also  possess  a  certainty  in  diagnosis,  and  a  large  number  of 
affections  hitherto  not  recognized  are  brought  within  the  reach  of 
topical  treatment.  I  have  found,  for  example,  that  affections  which 
were  wont  to  be  considered  general  diseases  involving  all  parts  of  the 
bladder  mucosa  may  in  reality  involve  only  a  small  part,  or  are  often 
distributed  in  patches  with  intervening  healthy  parts. 

I  have  found  also  that  so-called  irritable  bladder  in  women  is  a 
mild  inflammatory  affection  involving  either  a  small  part  of  the  tri- 
gonum  or  a  part  of  the  urethra,  and  is  a  disease  readily  amenable 
to  treatment. 


DISEASES  OF  THE   URETHRA.  695 

The  method  does  away  forever  with  the  incision  of  the  bladder  for 
diagnostic  purposes,  or  the  incision  and  dilatation  of  the  urethra  for 
the  purpose  of  introducing  the  finger  into  the  bladder. 

By  catheterizing  the  ureters  in  the  simple  manner  described  we 
do  away  with  the  necessity  of  fishing  for  them  with  a  catheter  intro- 
duced through  the  urethra,  guided  by  the  eye  watching  its  point 
playing  over  the  anterior  vaginal  wall.  This  method  of  Pawlik  is 
always  more  or  less  uncertain,  is  quite  difficult,  and  attended  with 
injury  to  the  bladder,  and  in  inflammatory  cases  is  particularly 
dangerous. 

We  can  by  this  means  exclude  renal  disease  where  pus  is  found  in 
the  urine,  or  we  can  diagnose  unilateral  or  bilateral  renal  disease. 

We  can  also  always  readily  ascertain  the  sources  of  hemorrhage. 

We  are  thus  enabled  to  treat  pyelitis  and  pyo-ureter  and  stricture 
of  the  ureter  in  its  lower  part. 

Treatment  can  be  applied  directly  to  the  parts  affected  without 
unnecessarily  treating  the  sound  surfaces. 

We  may  also  follow  up  the  method  of  treatment  from  week  to 
week  without  discomfort  to  the  patient,  and  with  certainty  as  to 
results. 

DISEASES  OF  THE   URETHRA. 

Diseases  of  the  urethra  in  the  female  often  escape  the  attention  of 
gynecologists,  either  because  of  the  difficulties  of  the  examination, 
instruments  different  from  those  with  which  they  are  most  familiar 
being  required,  or  because  these  diseases  are  so  often  found  so 
associated  with  other  grave  genital  affections  that  the  urethral  dis- 
turbance is  liable  to  be  passed  over  as  secondary,  or,  if  noticed  at 
all,  to  receive  inadequate  attention. 

I  propose  to  speak  of  the  diseases  of  the  urethra  under  the  follow- 
ing heads:  (1)  Malformations;  (2)  Displacements;  (3)  Variations  in 
calibre;   (4)  Fistulse;   (5)  Inflammatory  diseases;  (6)  New  growths. 

Malformations. 

Commonest  of  all  malformations  of  the  urethra  is  a  marked  lat- 
eral disi>lacement  or  obliquity  of  the  external  orifice.  When  the  ure- 
thral orifice  appears  distinctly  on  one  side,  there  is  apt  to  be  a  shal- 
low vertical  fissure  at  a  corresponding  point  on  the  opposite  side, 
with  a  ridge  Ijetween  the  two,  apj^earing  to  indicate  an  early  embry- 
onic double  urethra. 

Otlier  malformations  are  due  to  failure  in  the  development  of 
some  portion   of  the  urethral  wall  in  embryonic   life.     These  are 


696  KELLY — DISEASES   OF  THE  FEMALE  BLADDER  AND  URETHRA. 

called,  accordingly  as  tlie  defective  part  is  tlie  external  or  internal 
portion  of  the  urethra,  defectus  urefhrce  externus  and  defectus  iirethrce 
internus.  If  the  whole  urethra  is  wanting,  the  anomaly  is  described 
as  defectus  iirethrce  totalis.  If  a  portion  of  the  anterior  inferior  wall 
is  absent,  the  condition  is  one  of  hyposjjadias. 

These  anomalies  of  the  urethra  are  as  a  rule  associated  with  other 
anomalies  of  the  external  and  internal  genital  organs. 

Defectus  Urethroe  Toicdis. — In  total  absence  of  the  urethra  its 
rudiments  are  in\dsible  externally,  and  the  opening  for  the  discharge 
of  the  urine  exists  in  the  form  of  a  slit  in  the  base  of  the  bladder.  In 
a  case  of  Langenbeck's,  cited  by  Winckel,  a  girl  of  nineteen  had  an 
imperforate  hymen,  the  urethra  was  absent,  and  vagina  and  bladder 
formed  a  common  canal. 

Atresia  of  the  Urethra. — In  this  case,  the  urethra  is  open  as  far 
as  the  bladder,  which  is  closed  and  together  with  the  ureters  dilated. 
Schatz  has  reported  a  case  in  which  the  urethra  ended  in  a  cul-de-sac 
5  mm.  long.  The  rest  of  the  urinary  apparatus  and  the  internal 
genitals  were  completely  divided  into  right  and  left,  and  the  bladders 
opened  into  the  vagina  through  congenital  vesico-vaginal  fistulas. 

Hypospadias. — In  hj^pospadias,  the  anterior  and  some  of  the 
lateral  urethral  walls  are  present  and  indicated  by  a  furrow,  while 
the  inferior  wall  is  absent  from  the  external  orifice  to  a  greater  or 
less  extent  backward ;  the  urethra  thus  opens  well  within  the  vagina. 
In  one  instance  of  this  kind,  in  the  case  of  a  woman  forty-six  years 
old,  the  common  urinary  and  vaginal  orifice  lay  small  and  contracted 
underneath  the  symphysis.  A  half  an  inch  farther  in,  it  was  divided 
into  three  passages,  the  anterior  being  the  urethra,  which  was  an 
inch  long,  and  the  posterior  a  double  vagina  nearly  three  inches  long. 

Many  of  these  affections  do  not  call  for  treatment,  being  either 
anomalies  occasioning  death  in  foetal  life,  as  in  the  case  of  atresia,  or 
associated  with  other  serious  malformations  of  the  external  genitals. 

Mandl  has  reported  a  case  ( Wiener  kUnische  Wochenschrift,  1891, 
page  515) ,  of  retention  of  urine  for  two  days  in  a  child,  with  a  con- 
genital atresia ;  the  retention  was  accompanied  by  vomiting  and  con- 
vulsions. The  atresia  was  broken  through  by  passing  a  sound  into 
the  bladder,  and  the  symptoms  were  entirely  relieved. 

Displacements  of  the  Urethra. 

There  are  in  general  four  forms  of  displacement  of  the  urethra : 
(1)  Displacement  upward;  (2)  Moderate  downward  displacement. 
(3)  Complete  displacement  of  the  whole  urethra  downward ;  (4)  Pro- 
lapse of  the  mucous  membrane  of  the  urethra  at  the  external  orifice. 


DISPLACEMENTS  OF  THE   URETHRA. 


697 


Upioard  displacement  is  seen  in  association  with  pelvic  tumors, 
more  particularly  large  my omata  lifting  the  uterus  up  into  the  ab- 
dominal cavity,  and  pulling  along  with  it  both  bladder  and  urethra. 
In  these  cases  the  urethra  may  be  so  drawn  up  and  flattened  by  com- 
pression between  the  tumor  and  the  symphysis  as  to  make  the  pas- 
sage of  the  catheter  both  difficult  and  dangerous.  A  similar  difficulty 
is  often  experienced  in  catheterizing  during  labor,  when  the  head  of 
the  child  is  well  engaged 
in  the  pelvis.  I  know  of 
an  instance  in  which  the 
doctor,  not  appreciating 
this  difference  in  the  di- 
rection of  the  urethra  in 
the  parturient  woman,  in 
his  efforts  to  draw  off  the 
urine  before  performing  a 
Caesarean  section,  perfo- 
rated the  posterior  wall 
of  the  urethra  with  the 
catheter  and  even  forced 
the  latter  into  the  child's 
head  several  times,  bring- 
ing away  some  of  the 
brain  in  the  eye  of  the 
instrument.  The  opera- 
tion was  not  performed, 
and  the  woman  passed  a 
dead  child  with  several 
small  holes  in  its  head. 

This  displacement  will 
be  relieved  when  the  tu- 
mor has  been  removed, 
letting  the  bladder  and 
urethra  down  to  their  nor- 
mal relations  within  the 
pelvis. 

A  moderate  downward  displacement  is  found  associated  with  a  de- 
scensus uteri  and  a  dropping  of  the  anterior  vaginal  wall  and  the 
formation  of  a  cystocele. 

Complete  downward  displacement  of  the  urethra  occurs  commonly 
with  a  prolapsus  uteri.  The  direction  of  the  urethra  in  these  cases 
is  at  right  angles  to  its  former  position.  Owing  to  this  extreme  dis- 
placement, which  removes  the  urethra  from  the  line  of  effective  intra- 


FiG.  84.— Dilatation  of  External  Urethral  Orifice.    Displace- 
ment of  urethra  and  bladder  associated  with  complete  tear 


698  KELLY — DISEASES   OF  THE  FEMALE  BLADDER  AND  URETHRA. 

abdominal  pressure,  as  well  as  from  its  relation  to  the  diverticulum  of 
the  bladder,  the  difficulty  of  emptying  the  bladder  in  prolapse  is  very 
great  and  considerable  urine  is  almost  always  left  behind. 

This  difficulty  is  corrected  by  the  appropriate  operation  for  the 
prolapsus,  restoring  the  organs  to  their  normal  position. 

Prolapse  of  the  mucous  membrane  of  the  urethra  is  a  disease  more 
common  at  the  extremes  of  life..  It  has  thus  been  noticed  in  little 
children  a  few  months  or  a  few  years  old,  and  in  women  of  from 
forty-five  to  sixty  years  of  age  and  over. 

In  the  case  of  women  it  is  usually  an  eversion  of  that  part  of  the 
mucous  membrane  lying  adjacent  to  the  external  orifice.  It  forms  in 
these  cases  an  intensely  red,  highly  vascular  tumor,  in  the  centre  or 
to  one  side  of  which  the  urethral  canal  is  found.  In  one  case  ob- 
served by  Bagot  in  a  woman  aged  thirty-two,  the  extruded  part  be- 
came gangrenous  and  sloughed  off. 

In  little  children,  on  the  contrary,  the  relaxation  of  the  mucous 
membrane  and  the  eversion  take  place  from  within  outward.  The 
tumor  appears  at  the  external  orifice  and  may  project  an  inch  or  more 
bej^ond  it,  being  swollen,  deep-red  or  bluish-red,  sometimes  bathed 
in  pus.  It  has  been  noticed  as  a  sequence  of  severe  coughing  in 
whooping-cough,  or  straining  at  stool  in  diarrhoea,  and  following  the 
injury  produced  by  rape.  Weak,  anaemic,  and  scrofulous  children 
are  most  liable  to  it. 

The  treatment  should  not  be  by  galvano-cautery,  on  account  of 
the  danger  of  contraction  and  stricture  of  the  urethra,  and  it  is  of  no 
use  to  replace  the  tumor,  for  it  will  invariably  be  reproduced.  The 
treatment  which  has  been  adopted  with  the  most  success  has  been  the 
union  of  the  neck  of  the  tumor  with  the  margin  of  the  urethra  on  all 
sides,  by  interrupted  fine  silk  sutures.  Care  must  be  taken  to  pass 
the  suture  before  cutting  away  the  tumor,  lest  the  severed  mucous 
membrane  retract  within  the  urethra  and  bleed  indefinitely  before  it 
can  be  secured  again.  It  is  best  to  leave  a  catheter  in  the  bladder  for 
two  or  three  days. 

Variations  in  Calibre. 

Variations  in  calibre  of  three  kinds  are  found  in  the  urethra :  (1) 
stricture;  (2)  general  dilatation;   (3)  partial  dilatation. 

Stricture. 

Strictures  of  the  urethra  are  usually  circular  or  tubular  and  result 
from  an  antecedent  gonorrhoea.  Stricture  may  also  result  from 
trauma.     I  have  seen  one  case  of  carcinoma  in  which  the  urethra 


STRICTURE   OF  THE   URETHRA.  699 

was  narrowed  throiigliout  its  length  by  a  longitudinal  infiltration 
parallel  to  the  canal.  Marked  narrowing  of  the  urethra  is  also  not 
uncommonly  observed  when  carcinoma  involves  the  urethro-vaginal 
septum. 

Yan  de  Warker  lays  great  stress  upon  strictures  of  the  urethra  of 
larger  calibre,  comparing  them  to  these  strictures  in  the  male.  In- 
deed he  thinks  they  are  more  frequent  than  in  the  male,  and  result 
either  from  gonorrhoea  or  from  trauma  in  childbirth.  They  are  more 
rare  in  young  women.  These  strictures  are  not  to  be  detected  by  an 
ordinary  sound.  The  best  way  to  detect  their  presence  is  by  passing 
an  olive-pointed  bougie  which  trips  over  the  ring  of  the  stricture  as 
it  is  withdrawn. 

The  diagnosis  of  stricture  of  small  calibre  is  often  made  accident- 
ally in  the  difficulty  experienced  by  the  first  attempt  to  catheterize  the 
patient.    In  one  of  my  cases,  in  which  I  performed  a  cholecystotomy, 

1  was  able  only  with  difficulty  to  introduce  a  catheter  2  mm.  in  diam- 
eter through  a  stricture  which  lay  immediately  behind  the  meatus. 
In  another  case  suffering  from  extensive  ulceration  of  the  external 
genitals  and  elephantiasis,  the  lower  part  of  the  urethra  was  con- 
verted into  a  rigid  tubular  canal. 

Upon  introducing  the  speculum  the  contracted  lumen  of  the  stric- 
tured  urethra  is  seen  closing  over  in  front  of  the  orifice  of  the 
speculum,  which  cannot  be  pushed  any  farther  in  without  undue  force. 

Treatment. — This  consists  in  dilatation  by  graduated  bougies, 
which  is  usually  not  difficult,  on  account  of  the  shortness  of  the  canal 
making  the  stricture  easily  accessible.  The  best  dilators  are  slightly 
sigmoid  in  shape,  the  sizes  increasing  a  half-millimeter  each  time 
from  3  mm.  up  to  12  mm.    At  one  treatment  sufficient  dilatation,  from 

2  to  5  or  6  mm. ,  can  be  obtained  to  allow  the  urine  to  pass  readily. 
At  the  subsequent  treatments,  the  dilatation  can  be  carried  up  to  8 
or  10  mm.,  at  which  point  it  must  be  maintained. 

For  the  first  thorough  examination  it  is  best  to  give  anaesthesia, 
and  afterward  to  continue  the  dilatations  under  cocaine. 

It  is  important  to  keep  these  cases  under  observation  a  long  time, 
because  a  stricture  which  has  been  dilated  shows  a  persistent  ten- 
dency to  contract  again.  In  one  of  my  cases  I  had  a  dilator  made 
the  size  of  one  of  my  No.  8  endoscopes,  that  is,  8  mm.  in  diameter, 
and  taught  the  patient  to  pass  it  herself.  I  saw  her  a  year  later  and 
learned  that  by  using  the  dilator  at  intervals  she  had  had  no  fur- 
ther difficulty. 

Where  the  injury  to  the  anterior  part  of  the  urethra  is  extensive  and 
associated  with  a  large  amount  of  cicatricial  tissue,  it  will  be  better 
to  buttonhole  the  urethra  behind  the  stricture,  by  incising  the  ure- 


700 


KELLY— DISEASES   OF  THE  FEMALE  BLADDER  AND  URETHRA. 


thro-vaginal  septum,  taking  care  not  to  toucli  the  neck  of  the  bladder 
by  keeping  as  far  anterior  to  it  as  the  stricture  permits,  and  attaching 
the  mucous  membrane  of  the  urethra  on  all  sides  to  the  mucous  mem- 
brane of  the  vagina. 

General  Dilatation. 

Eelaxation  of  the  urethra  as  a  whole  is  most  frequently  observed 
in  cases  where  coitus  has  taken  place  per  urethram,  or  where  the 
urethra  has  been  dilated  by  the  finger  for  the  examination  of  the  blad- 


Fig.  85.— Extreme  Dilatation  of  Urethra  Through  Coitus.     Atresia  of  vagina, 
introduced  into  the  bladder,  thumb  in  the  rectum. 


Index  finger 


der,  or  for  the  extraction  of  a  stone.  Cases  of  relaxation  due  to  the 
latter  cause  are  fortunately  becoming  rare,  and  ought  never  to  occur. 

Belaxation  due  to  coitus  per  urethram  is  found  in  cases  of  mal- 
formation of  the  external  genitals  interfering  with  coitus  per  vagi- 
nam,  as  in  the  case  of  imperforate  hymen,  or  absence  of  the  vagina. 
I  saw  an  extreme  case  of  relaxation  of  this  form  in  one  of  my  cases,  in 
which  the  urethra  lay  inside  the  vaginal  orifice  behind  the  symphysis 
pubis,  and  below  it  were  two  small  orifices  divided  by  the  septum ;  it 
was  a  case  of  double  vagina,  so  placed  as  not  to  be  infringed  upon  by 
any  large  body  introduced  from  without. 

Another  class  of  cases  is  that  in  which  atresia  has  been  acquired 
through  inflammatory  affections   following   childbirth;   thus  in  the 


DILATATION   OF   THE   URETHEA.  701 

patient  figured  in  the  text,  a  black  woman,  the  vagina  was  closed 
down  to  a  fine  fistulous  orifice  about  the  size  of  a  hair.  The  only 
trace  of  the  vagina  left  below  the  atresia  was  a  little  pocket.  Above 
was  a  large  hsematokolpos  and  hsematometra.  The  urethra  was  so 
relaxed  that  in  examining  the  patient  the  index  finger  passed  at  once 
into  the  bladder  without  the  examiner  being  conscious  of  the  abnor- 
mal condition.  When  the  patient  was  anaesthetized  two  fingers  could 
easily  be  carried  into  the  bladder. 

The  symptoms  produced  by  this  condition  are  variable.  Where 
the  urethra  has  been  broken  down  by  an  examination  or  by  dragging 
out  a  stone,  persistent  incontinence  may  be  the  result,  the  patient 
having  no  power  to  control  the  flow  of  urine,  which  dribbles  contin- 
ually over  her  person.  In  relaxations  from  coitus,  strange  to  say, 
the  patients  are  not  usually  troubled  with  incontinence,  being  able  to 
hold  the  urine  two  or  three  hours.  But  it  usually  escapes  when  the 
woman  laughs  or  during  the  strain  of  sudden  lifting. 

Treatment.— y^h&a.  the  relaxation  is  due  to  coitus,  it  will  be  best 
not  to  touch  it  unless  the  vaginal  canal  can  be  restored.  In  the  case 
of  the  black  woman  above  referred  to,  the  urethra  was  relieved  of  its 
abnormal  function  by  an  operation  establishing  the  integrity  of  the 
vaginal  canal.  The  case  of  relaxed  urethra  with  double  vagina  was  re- 
lieved by  a  plastic  operation  bringing  the  lower  margin  of  the  urethra 
farther  forward,  and  by  cutting  away  the  septum  between  the  two 
halves  of  the  vagina,  substituting  a  single  larger  for  two  smaller  func- 
tionally useless  canals. 

Where  the  incontinence  is  due  to  manual  or  instrumental  break- 
ing down  of  the  canal,  Schultze  has  recommended  an  operation  to  re- 
store the  urethra  with  the  neck  of  the  bladder  to  its  normal  calibre, 
by  first  splitting  the  vaginal  mucosa  over  the  urethra  and  then  draw- 
ing out  the  excess  of  the  dilated  canal  and  cutting  it  off  with  sharp 
scissors,  uniting  the  raAv  surfaces  again  by  suture. 

Winckel  treated  a  case  by  excision  of  a  piece  of  the  anterior  vagi- 
nal wall  8  cm.  (3  in.)  long,  and  from  1  toli  cm.  (^  tof  in.)  in  breadth, 
beginning  at  the  very  margin  of  the  urethra.  The  wounded  surface 
thus  exposed  was  closed  with  twelve  silkworm-gut  sutures.  He  did 
this  at  first  without  removing  any  of  the  mucous  membrane,  and  the 
imjjrovement  was  but  moderate.  At  a  second  operation  a  piece  2^ 
cm.  long  by  1^  cm.  broad  was  excised,  including  a  piece  of  the  mucous 
membrane  of  the  urethra  from  4  to  5  mm.  in  breadth,  as  recom- 
mended l^y  Frank  in  Cologne,  in  the  Centralhlattfdr  Gyndkologie,  No. 
9,  1882.  The  result  this  time  was  so  good  that  the  patient  was  able 
to  hold  500  c.c.  of  urine  and  was  completely  relieved  of  the  trouble. 

Pawlik  cured  a  case  of  incontinence,  remaining  after  the  closure 


702  KELLY — DISEASES   OF  THE  FEMALE  BLADDER  AND   URETHRA. 

of  a  large  vesico-vaginal  fistula,  by  excising  a  wedge-shaped  piece 
on  one  side  of  the  urethra  extending  a  short  distance  up  into  the 
vagina.  The  wound  was  brought  together  by  sutures,  and  after  it 
had  thoroughly  healed  a  similar  operation  was  performed  upon 
the  opposite  side.  The  result  of  both  operations  was  to  jjuU  the 
urethra  out  flat  by  tension  on  its  two  sides  and  to  produce  a  distinct 
bend  in  the  urethral  canal.  {Wiener  mediziniscke  Woclienschrift, 
1883,  Nos.  25  and  26.) 

Schatz  has  been  able  to  relieve  incontinence  by  the  use  of  funnel- 
shaped  pessaries  placed  within  the  vagina. 

A  similar  result  has  been  obtained  by  a  glass  ball  pressing  the 
neck  of  the  bladder  against  the  symphysis  pubis. 

Partial  Dilatation. 

Partial  dilatation  of  the  urethra,  or  urethrocele,  consists  of  a 
diverticulum  of  the  urethral  wall  encroaching  upon  the  vaginal  canal 
or  projecting  into  the  introitus.  In  this  condition  there  is  a  prolap- 
sus or  hernia  of  the  urethral  mucosa,  with  the  formation  of  a  rounded 
tumor  or  prominence  on  the  vaginal  surface  covered  by  the  vaginal 
mucosa.  This  form  of  urethrocele  must  not  be  mistaken  for  sub- 
urethral abscess  with  an  opening  communicating  with  the  urethra. 
It  is  also  still  more  important  not  to  mistake  the  downward  displace- 
ment and  rolling  out  of  the  lower  part  of  the  anterior  vaginal  wall  for 
a  urethrocele.  It  is  a  common  mistake  of  many  gynecologists  to  call 
all  these  misplacements  of  this  portion  of  the  vagina,  urethrocele. 

The  treatment  is  by  excision  of  a  wedge-shaped  piece  over  the 
dilated  portion,  removing  the  surplus  tissue,  including  the  whole 
thickness  of  the  septum.  The  edges  of  the  wound  are  brought  to- 
gether by  silkworm-gut  sutures,  and  a  catheter  is  retained  in  the 
canal  for  three  or  four  days. 

Urethro-Vaginal  Fistula. 

Fistula  affecting  the  urethro-vaginal  septum,  and  establishing  a 
communication  between  the  urethral  and  vaginal  tracts  without  in- 
volvement of  the  bladder,  is  rare. 

Such  fistulse  may  arise  from  slough  due  to  prolonged  pressure  dur- 
ing labor,  or  from  a  buttonhole  operation  by  which  the  communica- 
tion has  been  artificially  established  for  the  purpose  of  relieving  a 
urethrocele,  or  so-called  hemorrhoidal  condition  of  the  mucosa,  or 
on  account  of  a  tight  stricture  of  the  urethra. 

In  one  instance  I  observed  a  fistula  resulting  from  pressure,  in 
which  the  small  oval  opening  lying  just  in  advance  of  the  neck  of  the 


INPLAMMATOEY  AFFECTIONS  OF  THE   URETHRA.  703 

bladder  was  closed  by  silkworm-gut  sutures  after  freshening  of  its 
margin,  in  the  same  manner  as  in  vesico- vaginal  fistula.  The  sutures 
in  this  case  were  placed  transversely. 

In  another  of  my  cases  there  was  a  urethro-vaginal  fistula  about  a 
half-centimetre  in  advance  of  the  neck  of  the  bladder,  and  imme- 
diately behind  it  a  vesico-vaginal  fistula  about  2  cm.  in  diameter. 
The  anterior  part  of  the  urethra  was  entirely  uninjured.  The  proced- 
ure in  this  case,  which  was  a  peculiar  one,  was  entirely  successful. 
The  tissue  at  the  neck  of  the  bladder  was  not  sufficient  in  amount  to 
allow  a  double  denudation  on  anterior  and  posterior  surfaces,  neces- 
sary to  close  the  vesico-vaginal  and  urethro-vaginal  fistulse  in  the  or- 
dinary way.  The  following  procedure  was  therefore  adopted :  The 
bridge  of  tissue  forming  the  neck  of  bladder  was  disregarded,  and 
the  oval  denudation  made  to  include  both  fistulse  as  if  they  were 
one.  The  edges  of  the  wound  were  brought  together  by  silkworm-gut 
sutures  passed  antero-posteriorly.  The  result  was  that  urine  dis- 
charging from  the  bladder  could  pass  either  above  the  bridge  of  tissue 
into  the  internal  orifice  of  the  urethra,  or  below  it,  by  a  short  circuit 
into  the  upper  urethra.  There  was  no  incontinence  as  a  result  of  the 
operation. 

Inflamniatory  Affections  of  the  Urethra. 

Inflammation  of  the  female  urethra  is  a  disease  of  much  greater 
frequency  than  is  usually  suspected  or  diagnosed.  The  explanation 
of  this  lies  in  the  fact  that  patients  complaining  of  characteristic  in- 
flammatory symptoms  are  not  often  subjected  to  a  painstaking  en- 
doscopic examination. 

Numbers  of  cases  of  urethritis  are  diagnosed  from  their  symp- 
toms as  cystitis  and  persistently  treated  as  such  for  long  periods  of 
time.  I  have  at  present  under  my  care  a  patient  who  was  treated  in 
a  hospital  for  some  months  for  irritable  bladder,  where  examination 
revealed  the  fact  that  she  had  an  inflammatory  disease  limited  to  the 
anterior  jjaii  of  the  urethra  and  a  small  area  near  the  internal  orifice. 

Inflammation  of  the  urethra  is  due  to  infection,  and  must  be  dis- 
criminated from  hypersemia  due  to  a  mechanical  or  chemical  irritant. 

The  most  common  cause  of  inflammation  is  the  gonococcus.  In 
the  aggravated  form  of  gonorrhoeal  inflammation  of  the  urethra, 
ulceration  may  also  be  present. 

The  urethra  may  also  be  the  seat  of  syphilis,  tubercular  ulcers, 
and  diphtheritic  patches. 

A  mild  form  of  urethritis  not  infrequently  exists  in  women  where 
there  has  Ijeen  no  0}>portunity  for  infection  by  contagion,  and  where 
there  can  be  no  suspicion  of  gonorrhoea.    The  disease  is  apt  to  be  most 


704  KELLY— DISEASES   OF   THE   FEMALE   BLADDER   AND   URETHRA. 

marked  in  the  anterior  and  posterior  parts  of  tlie  urethra.  The  mucous 
membrane  becomes  swollen  and  deep-red,  and  the  vessels  are  injected. 
Upon  examination,  unless  the  speculum  is  handled  with  extreme  care, 
the  mucosa  is  injured  and  a  little  bleeding  results.  The  glands  of  the 
urethra  stand  out  prominently,  appearing  as  oval  yellow  spots  a  few 
millimetres  long.  In  the  anterior  part  of  the  urethra  a  little  secretion 
is  often  discharged  from  one  of  the  crypts,  as  it  comes  into  view  in 
the  lumen  of  the  speculum.  This  looks  like  pus,  but  may  be  nothing 
more  than  epithelial  debris.  The  tenderness  throughout  is  very 
marked. 

Treatment  of  this  form  of  trouble  is  both  simple  and  satisfactory. 
The  inflamed  parts  are  touched  once  in  four  or  five  days  with  a  weak 
solution  of  nitrate  of  silver,  usually  not  more  than  three  per  cent,  in 
strength.  From  five  or  six  to  a  dozen  applications  will  usually  clear 
up  the  trouble. 

In  gonorrhoeal  urethritis,  the  mucosa  of  the  urethra  becomes  so 
swollen  that  there  is  no  longer  room  for  it  in  the  urethral  canal,  and 
it  pushes  down  and  prolapses  at  the  external  orifice,  where  it  pouts 
out  of  a  deep  red  color,  at  a  later  stage  to  be  bathed  in  pus.  The  parts 
are  so  exquisitely  tender  that  they  cannot  be  handled,  much  less  can 
a  speculum  be  introduced,  without  anaesthesia.  Bleeding  is  often 
spontaneous  and  is  sure  to  occur  upon  the  introduction  of  an  instru- 
ment. An  examination  of  the  secretion  under  the  microscop)e  shows 
gonococci.  The  urethral  ducts  described  by  Skene  are  often  involved, 
and,  long  after  the  disease  has  subsided  in  the  rest  of  the  urethra,  may 
remain  in  the  state  of  chronic  inflammation,  secreting  pus.  This 
pus,  as  has  been  pointed  out,  may  become  the  source  of  repeated 
relapses  by  reinfecting  the  mucous  membrane  after  the  disease  has 
been  cured  elsewhere,  in  a  manner  entirely  analogous  to  the  similar 
inflammation  of  the  ducts  of  Bartholini's  glands.  It  is  important, 
therefore,  always  to  watch  for  this  complication,  and  in  cases  which 
have  sur%dved  an  attack  of  specific  urethritis,  to  investigate  the  con- 
dition of  these  glands.  This  is  done  by  milking  their  contents 
down  through  the  orifice  opening  into  the  urethra,  while  pulling  the 
urethral  orifice  open  and  exposing  the  duct.  The  anterior  vaginal 
wall  just  under  the  symphysis  is  stroked  downward  on  one  side  from 
a  point  about  three  centimetres  to  the  inner  side  of  the  urethral  orifice. 
The  position  of  the  finger  in  thus  emptying  the  ducts  is  shown  in  the 
illustration  (Fig.  86).  The  appearance  of  the  urethral  orifice  with 
a  drop  of  pus  on  one  side  issuing  from  the  right  duct  is  drawn  from 
life  and  is  entirely  characteristic. 

The  treatment  of  gonorrhoeal  urethritis  is  by  rest,  hot  vaginal 
douches,  the  application  of  lead-water  and  laudanum  to  the  external 


SUB-URETHEAL  ABSCESS. 


705 


parts,  if  swollen  and  tender,  and  the  administration  of  such  reme- 
dies as  are  used  in  the  male,  together  with  sedative  suppositories  if 
necessary. 

In  the  more  chronic  condition,  the  passage  of  a  No.  10  speculum 
and  the  application  once  every  five  to  seven  days  of  a  two-  to  three- 
per-cent.  solution  of  nitrate  of  silver  to  the  part  most  affected  will  be 


Fig. 


-Expression  of  Pus  from  the  Urethral  Duetf 


of  great  benefit.      The  general  supporting  tonic  treatment  of  the 
patient  must  also  not  be  forgotten. 

SUB-UEETHEAL   AbSCESS. 

I  desire  under  this  subject  to  call  attention  to  a  curious  affection 
of  the  urethro-vaginal  septum,  whose  etiology  is  still  obscure. 

An  abscess  is  found  in  rare  cases  distending  the  urethro-vaginal 
septum  and  ijrojecting  down  into  the  lumen  of  the  vagina.  It  varies 
from  the  size  of  a  small  nut  up  to  that  a  hen's  egg.  It  is  well  defined, 
rounded,  and  extremely  tender  to  the  touch,  and  is  often  associated 
with  i^ainful  micturition  and  the  intermittent  discharge  of  pus  from 
the  urethra.  Coitus  is  extremely  painful.  The  examination  is  best 
made  under  anaesthesia,  as  the  patient  shrinks  from  the  slightest 
touch.  On  pressing  on  the  tumor  pus  escapes  from  the  urethra  and 
the  tumor  sensibly  diminishes  in  size. 
Vol.  I.—ir, 


706 


KELLY — DISEASES   OF   THE   FEMALE   BLADDEE   AND    URETHEA. 


In  a  case  of  my  own, 
described  in  the  Johns 
Hopkins  Hospital  Bulletin, 
April,  1894,  the  patient 
was  colored,  31  years  of 
age,  married,  and  child- 
less. Sexual  relation  was 
painful  from  the  first.  For 
four  years  she  had  noticed 
a  small  lump  in  the  vagi- 
na, and  an  occasional  dis- 
charge of  pus  from  the 
urethra  during  the  inter- 
vals between  micturition. 
An  ovoid  mass,  3  by  2^  cm. 
in  size,  was  found  under  the 
urethra  (see  Fig.  87) ,  pres- 
sure upon  which  caused  the 
escape  of  pus  from  the  ure- 
thral orifice.  The  urethro- 
scope showed  a  little  de- 
pression in  the  urethral 
floor  a  short  distance  from 
the  internal  orifice.  A 
probe  was  inserted  at  this 
point,  and  on  making  pres- 
sure on  the  vaginal  side,  pus  was  seen  oozing  through  the  opening. 
The  relations  of  the  parts  are  shown  in  the  diagram  (Fig.  88) . 

Various  explanations  have 
been  ofi"ered  as  to  the  cause 
of  this  trouble  which  it  will 
not  be  necessary  to  discuss 
here.  I  believe  the  probabil- 
ity is  that  the  abscess  is  due 
to  the  infection  of  Skene's 
ducts,  with  closure  of  the  ori- 
fice and  subsequent  perfora- 
tion of  the  floor  of  the  urethra, 
as  in  the  formation  of  an  ab- 
scess of  Bartholini's  gland. 
The  treatment  is  either  by 

Fig.  88.— Sagittal  Section  Showing  Relations  of  Sub-      incision    extending    thrOUgh- 
urethral   Abscess  to  Urethra  and  Vagina  and  its  ^  ,     ,  j.      l       t   i.\^ 

Avenue  of  Discharge  per  Urethram.  OUt   the    whoie    extent    OI   tJlB 


Fig.  87.— Sub-urethral  Abscess,  Resembling  Urethrocele. 


NEW  GEOWTHS   OF  THE  FEMALE   URETHRA.  707 

sac,  packing  with  gauze,  and  keeping  tlie  incision  open  until  it  closes 
by  granulation ;  or  by  excision  removing  an  elliptical  piece  of  the  vagi- 
nal mucosa  and  carefully  dissecting  out  the  whole  cyst  wall  down  to 
the  urethra,  which  is  left  intact,  followed  by  immediate  closure  of 
the  wound  by  silkworm-gut  sutures. 

Calculus. 

Calculus  of  the  anterior  vaginal  wall  of  a  woman,  aged  sixty-seven, 
is  described  by  Cheron  in  the  Gazette  des  Hopitaux,  1887.  Cheron 
opened  the  sac  projecting  into  the  vagina  with  a  galvano-caustic  loop, 
and  removed  a  stone  weighing  twenty  grams.  This  urethral  calcu- 
lus appears  to  have  arisen  from  a  small  renal  calculus  lodging  in  the 
urethra. 

Piasecki  {Nouvdles  Archwes  ct  Ohstetrique  et  cle  Gynecologie,  May, 
1892)  describes  the  case  of  a  patient,  aged  sixty-five,  who  had  been 
suffering  for  twenty-five  years  with  pain  and  frequent  micturition. 
He  found  a  tumor  as  big  as  a  nut,  containing  a  phosphatic  calculus, 
in  the  posterior  urethral  wall.  The  tumor  was  removed  by  incision 
through  the  vagina. 

New  Growths   of  the  Female  Urethra. 

The  portion  of  the  urethra  which  is  more  liable  to  be  affected  by 
new  growths  is  the  external  meatus. 

At  this  point  we  may  meet  with  condylomata,  vascular  outgrowths, 
called  urethral  caruncle,  mucous  polyps,  carcinoma,  and  sarcoma. 

Condyloma. — Condylomata  are  little  warty  growths  generally  found 
in  association  with  similar  disease  of  other  parts  of  the  external  gen- 
itals, of  a  pale  color,  more  or  less  pedunculated,  and  not  sensitive  or 
bleeding  readily.  Their  microscopic  characteristics  are  those  of  the 
condylomata  elsewhere.  They  may  be  snipped  off  with  scissors  and 
the  base  touched  with  galvano-cautery  to  check  hemorrhage. 

Caruncles. — Urethral  caruncle  is  a  disease  of  the  external  meatus 
involving  one  or  both  lips ;  it  appears  as  a  deep  raspberry  red  tumor, 
projecting  well  beyond  the  lumen  of  the  urethra,  exquisitely  sensi- 
tive, and  bleeding  readily  upon  touch.  These  tumors  are  made  up  of 
connective  tissue  and  an  extensive  network  of  blood-vessels.  Their 
sensitiveness  is  often  so  extreme  as  to  cause  the  patient  the  greatest 
agony  in  passing  urine.  It  is  not  yet  precisely  known  to  what  the 
sensitiveness  is  due,  whether  to  unusual  nerve  sui)ply,  or  to  the  baring 
of  the  nen'^e  endings  by  the  destruction  of  the  epithelium  on  the 
surface. 

The  treatment  of  this  affection  is  by  excision  of  tlie  tumor  at  its 


708  KELLY — DISEASES   OF  THE  FEMALE  BLADDER  AND  UEETHEA. 

base,  under  cocaine  aneesthesia,  bringing  together  the  edges  of  the 
wound  by  the  finest  silk  suture.  The  galvano-cautery  has  been  used, 
but  is  unsafe  where  the  disease  is  extensive,  as  it  is  liable  to  be  fol- 
lowed by  a  cicatricial  contraction  of  the  urethral  orifice. 

Polyps  of  the  Urethra. — Delfosse  {Revue  cV  Ohstetriqueetde  Gynecolo- 
gie,  1892)  reports  a  case  of  a  patient  twenty-five  years  of  age  who  suf- 
fered violent  pains  in  urinating.  On  inspection  he  found  numerous 
little  tumors  at  the  urethral  orifice,  and  with  the  urethroscope  dis- 
covered that  the  whole  urethra  was  covered  with  small  polyps.  He  re- 
moved these  with  the  curette,  which  occasioned  but  little  loss  of  blood. 
The  pain  had  disappeared  by  the  fourth  day,  and  four  months  later 
there  was  no  return  of  the  disease. 

Concretions  have  been  observed  in  the  urethral  glands  of  the  fe- 
male, analogous  to  the  prostatic  concretions  in  the  male. 

Carcinoma. — Carcinomatous  disease  may  affect  the  urethra  by  ex- 
tension from  the  surrounding  parts,  such  as  the  cervix  or  the  exter- 
nal genitals.  Primary  carcinoma  of  the  urethra  is  extremely  rare. 
Cases  of  cancer  affecting  the  vestibule  and  so  rapidlj^  involving  the 
urethra  have  been  described.  Patients  affected  with  carcinoma 
present  no  specially  characteristic  symptoms.  The  urethral  orifice 
is  found  to  be  the  seat  of  a  tumor  which  api^ears  red,  bleeds  easily, 
erodes  and  breaks  down  in  places,  and  is  not  tender  to  the  touch. 
The  proliferation  of  tissue  and  the  breaking-down  may  be  so  marked 
as  to  leave  no  doubt  at  any  time  as  to  diagnosis. 

The  treatment  of  the  disease  will  depend  upon  the  stage  at  which 
it  has  been  discovered.  If  a  patient  has  applied  early  for  treatment, 
Avhile  the  disease  is  still  limited  to  the  neighborhood  of  the  external 
urethral  orifice,  it  may  be  excised,  a  wide  margin  of  tissue  being 
removed  on  all  sides.  When  the  affection  has  travelled  up  the  ure- 
thra to  the  bladder,  and  there  is  some  surrounding  infiltration,  ope- 
rative procedures  will  be  of  no  benefit. 

Sarcoma. — Sarcoma  of  the  urethra  has  been  described  by  Beigel. 
The  tumor  was  the  size  of  a  walnut,  situated  on  the  margin  of  the 
urethral  orifice.  It  contained  numerous  spaces  with  colloid  material. 
The  treatment  was  by  extirpation. 

DISEASES   OF   THE   FEMALE   BLADDER. 

Apart  from  the  inflammatory  troubles,  diseases  of  the  bladder  in 
women  are  rare;  this  is  due  to  its  concealed  position,  behind  the 
symphysis  pubis  and  protected  by  the  strong  bony  walls  of  the  pelvis. 
Neoplasms  of  the  bladder  wall  are  particularly  rare,  in  which  respect 
this  viscus  presents  a  marked  contrast  to  the  uterus  immediately  ad- 


CONGENITAL  ANOMALIES   OF  THE  BLADDER.  709 

joining.  The  most  frequent  affections  are  hyperaemias,  especially  of 
the  triangular  area,  and  cystitis.  The  female  bladder  is  quite  liable 
to  fistulse,  an  affection  but  rarely  found  in  the  male.  Foreign  bodies 
of  various  sorts  are  also  found  in  the  female  bladder  much  more  often 
that  in  the  male. 

Congenital  Anomalies. 

Fissure  of  tJie  Anterior  Wall. — The  most  frequently  observed  con- 
genital anomaly  of  the  bladder  is  a  fissure  in  the  anterior  wall.  This 
is  produced  by  defective  union  of  the  right  and  left  halves  of  the  body 
in  early  embryonic  life,  and  varies  in  degree  all  the  Avay  from  a  failure 
in  the  development  of  the  anterior  urethral  wall  to  a  fissure  involving 
the  lower  part  of  the  anterior  bladder  wall,  or  one  extending  up  the 
anterior  abdominal  wall  a  variable  distance,  reaching  as  high  even  as 
the  umbilicus. 

In  the  mildest  form  of  this  defect,  in  which  the  anterior  urethral 
wall  alone  is  involved,  there  is  incontinence  of  urine,  the  clitoris  is 
divided  into  right  and  left  halves,  but  there  is  no  separation  of  the 
symphysis  pubis.  In  two  cases  related  to  me  by  Dr.  C.  P.  Noble, 
of  Philadelphia,  the  other  genital  organs  were  normal. 

In  the  more  extensive  cases  involving  the  anterior  wall  of  the  blad- 
der there  is  often  an  eversion,  or  exstrophy,  of  the  bladder  walls 
through  the  opening.  In  these  cases  the  ureteral  orifices  may  readily 
be  seen  with  the  urine  discharging  intermittently  from  them.  The 
ureters  are  frequently  found  to  be  dilated. 

I  will  briefly  indicate  the  line  of  treatment  without  going  into 
detail.  Where  there  is  a  simple  slit-like  defect,  the  sides  of  which 
can  be  approximated  without  difiiculty,  the  appropriate  operation  is 
a  denudation  of  the  margins  of  the  openings  and  approximation  by 
suture.  Where  the  defect  is  more  extensive,  and  a  urethra  exists, 
the  best  plan  of  treatment  will  be  by  sliding  flaps,  taken  from  the 
neighboring  portions  of  the  abdominal  walls,  over  the  exposed  por- 
tion and  uniting  them  by  their  edges. 

Double  Bladder. — Cases  of  division  of  the  bladder  into  two  halves 
are  exceedingly  rare,  and  as  a  rule  found  only  in  very  young  chil- 
dren. The  only  adult  case  on  record  is  that  related  by  Gerard 
Blasius,  of  Amsterdam,  in  his  "  Observationes  Medicse  Eariores," 
puVjlished  in  Amsterdam,  in  the  year  1700.  His  eighteenth  observa- 
tion, on  page  59,  is  as  follows :  "  A  divided  urinary  bladder.  Second 
case.  Seen  on  the  tenth  of  January,  1657,  at  the  post-mortem  ex- 
amination of  a  patient  who  died  of  i)hthisis.  The  exterior  of  the 
bladder  exhibited  simply  a  depression  throughout;  its  length,  but 
the  interior   was   divided  into  two  cavities  by  a  thick  membrane 


710  KELLY — DISEASES  OE  THE  FEMALE  BLADDER  AND  UEETHEA. 

extending  down  to  tiie  urethra,  into  whicli  each  cavity  emptied. 
Each  cavity  was  provided  with  but  one  ureter.  It  was  possible  by 
dissection  to  separate  the  bladders  completely. "  The  condition  found 
is  well  shown  in  his  twelfth  figure  on  page  114. 

Other  cases  similar  to  this  are  those  in  which  vertical  septa  are 
found  dividing  the  bladder  less  completely. 

Displacements  of  the  Bladder. 

Displacements  of  the  bladder  maj  be  conveniently  considered 
under  four  headings:  (1)  Displacement  upward;  (2)  Descensus  or 
partial  displacement  downward;  (3)  Extreme  displacement  down- 
ward of  a  portion  of  the  bladder ;   (4)  Ectopia,  or  eversion. 

None  of  the  displacements  above  referred  to,  except  the  last,  is  a 
disease  of  the  bladder  ^^er  se.  The  upward  and  downward  displace- 
ments are  due  to  the  traction  or  pressure  of  tumors,  or  are  associated 
with  a  prolapse  of  vagina  and  uterus.  Displacements  dependent  upon 
the  growths  of  tumors,  or  alteration  in  position  of  other  organs  which 
may  be  progressive,  are  liable  to  vary  in  degree  with  the  changing 
positions  of  these  organs,  and  are  corrected  when  the  associated 
causal  trouble  is  removed. 

Upward  Displacement  of  the  Bladdei'. — This  dislocation  is  most 
frequently  observed  in  cases  of  large  myomatous  uteri,  in  which  the 
tumors  develop  under  the  pelvic  peritoneum  and  spread  out  into  the 
broad  ligaments,  and  as  they  develop  upward  carry  the  bladder  along 
with  them. 

The  treatment  in  these  cases  must  be  directed  to  the  removal  of  the 
tumors,  by  means  of  which  the  bladder  is  let  down  to  the  pelvic  floor 
to,  or  even  below,  its  normal  position. 

Descensus,  or  Partial  Displacement  Doivnivard  of  the  Bladder. — 
This  difiiculty  is  observed  in  cases  in  which  the  vaginal  outlet  is 
broken  down  and  there  is  a  tendency  toward  prolapsus  uteri,  as  is 
seen  in  a  descent  of  the  cervix  toward  the  vaginal  outlet,  together 
with  a  dropping  down  of  the  anterior  vaginal  wall,  filling  the  open- 
ing. On  account  of  the  association  of  the  bladder  with  this  dis- 
placement of  the  anterior  vaginal  wall,  the  protruding  mass  is  com- 
monly called  a  cystocele.  Much  time  has  been  unnecessarily  wasted 
in  discussions  of  cystocele,  and  the  analogous  affection  of  the  poste- 
rior vaginal  wall— rectocele.  It  is  important  to  recognize  the  fact 
that  these  are  not  affections  per  se,  but  symptomatic  merely  of  a  con- 
dition of  the  vaginal  outlet. 

Treatment. — I  have  long  since  given  up  operation  upon  either  cys- 
tocele or  rectocele  alone.     "Where  the  relaxation  of  the  vaginal  outlet 


DISPLACEMENTS   OP  THE   BLADDER.  711 

is  not  marked  and  an  operation  is  not  indicated,  a  well-fitting  Hodge 
or  Gehrung  pessary,  especially  th.e  latter,  will  serve  to  lift  up  the 
anterior  vaginal  wall  and  relieve  the  bearing-down  discomfort.  The 
most  complete  relief  will  be  obtained  by  a  suitable  operation  upon 
the  relaxed  vaginal  outlet,  restoring  it  to  its  normal  size  and  position 
under  the  symphysis  pubis,  thus  building  up  the  posterior  vaginal 
wall  again,  and  giving  the  vaginal  canal  its  normal  direction  back- 
ward and  inward  toward  the  lower  part  of  the  sacrum.  This  gives 
support  to  the  anterior  vaginal  wall  and  effectively  relieves  the  cys- 
tocele. 

Extreme  Displacement  Downward  of  a  Portion  of  the  Bladder. — 
This  form  of  displacement  is  found  associated  with  prolapsus  uteri. 
Its  occurrence  is  due  to  the  intimate  union  between  the  bladder  and 
the  supra-vaginal  portion  of  the  cervix,  which  is  so  closely  attached  to 
it  that,  as  the  uterus  escapes  from  the  pelvis,  all  this  portion  of  the 
bladder  must  of  necessity  pass  out  with  it,  forming  a  large  diverticu- 
lum on  the  anterior  face  of  the  prolapse.  By  passing  a  sound 
through  the  urethra,  which  has  changed  its  direction  in  the  manner 
described  above  (p.  697) ,  the  lowest  part  of  the  diverticulum  will  be 
found  to  lie  just  above  the  cervix  uteri  at  the  most  dependent  part  of 
the  sac.  By  passing  the  sound  in  an  opposite  direction,  a  portion  of 
the  bladder  will  also  be  discovered  occupying  the  pelvic  cavity  above 
the  uterus.  When  distended  the  bladder  forms  a  bilobate  organ,  of 
which  the  outer  lobe  can  be  distinctly  felt  to  fluctuate  upon  touch. 

Women  suffering  from  prolapse  always  find  difficulty  in  empty- 
ing the  bladder,  and  unless  the  prolapsus  is  returned  each  time,  evac- 
uation is  never  complete.  The  presence  of  the  diverticulum  predis- 
poses to  cystitis,  if  infectious  material  once  finds  its  way  into  the 
bladder.     Large  numbers  of  calculi  may  also  form  in  the  sac. 

The  treatment  of  the  condition  is  the  same  as  that  for  prolapsus 
uteri.  The  operation  devised  for  the  relief  of  prolapsus  must  there- 
fore be  considered  not  simply  as  an  operation  for  the  retention  of  the 
uterus  within  the  j)elvis,  but  equally  for  the  permanent  correction  of 
the  disjjlacement  of  vagina  and  bladder.  Where  the  radical  plan  of 
retention  by  denudation  and  suture  is  out  of  the  question,  it  may 
be  effected  by  a  series  of  buried  silkworm-gut  sutures  encircling  the 
vagina  from  the  cervix  down  to  the  outlet,  narrowing  and  stiffening 
the  vaginal  canal  in  such  a  manner  as  to  render  prolapse  impossible. 
This  is  the  plan  recommended  by  Freund  of  Strassburg  {Centralblatt 
fiir  Gyndkohgie,  No.  47,  1893). 

Ectopia,  of  the  Bladder  Without  Fissure. — Three  cases  of  prolapse 
of  the  Vjladder  through  the  urethra  are  cited  in  an  article  by  Lichten- 
heim  (Langenheck.' 8  Archiv  fiir  Minische  Ohirurgie,  'Bd.  XV.).     The 


712  KELLY — DISEASES   OF  THE  FEMALE   BLADDEK  AND   UEETHKA. 

displacement  occurred  at  the  lower  part  of  the  abdomen,  where  the 
symphysis  pubis  was  separated.  The  tumor  protruded  in  the  form  of 
a  bright-red  mass,  which  was  easily  returned  through  the  defect  in  the 
lower  abdominal  wall.  There  was  no  defect  in  the  bladder  wall,  and 
therefore  the  retention  of  urine  was  not  interfered  with.  The  color 
of  the  tumor  was  due  to  its  investment  with  a  membrane  presenting 
the  characteristics  of  the  mucous  lining  of  the  bladder. 

Another  kind  of  prolapse  of  the  bladder  is  that  in  which  it  is 
forced  through  a  lax  urethra  and  out  through  the  external  urethral 
orifice,  where  it  appears  as  a  large,  bright-red  mass.  On  its  under 
surface  the  ureteral  openings  are  seen.  One  case  of  this  kind  together 
with  prolapse  of  vagina  and  rectum  has  been  observed  in  conse- 
quence of  a  fall  (v.  Winckel  in  Billroth  and  Luecke's  "Handbuch 
der  Frauenkrankheiten,"  Bd.  III.,  p.  421,  1886). 

Vesico-Vaginal  Fistula. 

Vesico-vaginal  fistula,  or  the  establishment  of  an  accidental  com- 
munication between  the  bladder  and  the  vagina  by  means  of  a  defect 
in  the  base  of  the  bladder,  is  not  infrequently  met  with  in  two  classes 
of  cases.  First,  those  in  which  a  cancerous  disease  extending  from 
the  cerAdx  uteri,  and  involving  the  vesico-vaginal  septum,  has  broken 
down  and  formed  an  avenue  of  communication;  second,  those  in 
which  a  protracted  labor  has  been  followed  by  sloughing  of  the  ante- 
rior vaginal  wall  during  the  puerperal  period.  Thej^  are  also  rarely 
seen  as  a  result  of  an  unhealed  incision  of  the  vaginal  wall  for  the  ex- 
traction of  stone.  The  cancerous  cases  are  not  amenable  to  treatment 
and  will  not  therefore  be  further  mentioned ;  the  mode  of  death  is  by 
progression  of  the  disease,  pressure  upon  the  ureters,  and  uraemia. 

Fistula  following  Labor. — Vesico-vaginal  fistula  may  follow  labor 
from  a  number  of  causes.  Without  doubt  the  most  common  cause  is 
prolonged  pressure  of  the  head  of  the  child  in  one  place,  in  con- 
sequence of  which  the  circulation  is  completely  cut  oif  and  the  tis- 
sues bruised;  in  the  course  of  five  or  six  days  or  a  week  a  slough 
more  or  less  neatly  punched  out  of  the  vesico-vaginal  septum  falls 
into  the  vagina  and  leaves  the  fistula.  Women  with  contracted 
pelvis,  or  with  a  sharp  bony  growth  on  the  posterior  surface  of  the 
symphysis,  are  more  liable  than  others  to  this  affection. 

It  has  been  the  habit  in  the  past  to  blame  the  use  of  the  forceps  in 
difficult  labors  for  the  production  of  this  trouble,  but  as  Emmet 
long  since  pointed  out  and  repeatedly  insisted  upon,  it  is  not  the 
use  of  the  forceps,  but  a  want  of  their  timely  use  to  relieve  the  pres- 
sure, which  is  to  blame. 


VESIOO-VAGINAL  FISTULA,  713 

Yesico-vaginal  fistula  also  arises  in  consequence  of  a  tear  through 
the  anterior  lip  of  the  cervix  extending  out  into  the  vaginal  vault,  and 
up  through  the  whole  septum.  This  tear  also  usually  extends  into 
the  uterus,  forming  a  vesico-utero-vaginal  fistula.  Not  infrequently 
nature  will  unite  the  lips  of  the  cervix  below,  leaving  a  vesico-uterine 
fistula  above  and  a  vesico-vaginal  fistula  beneath,  separated  by  a 
bridge  of  uterine  tissue.  The  clinician  must  be  careful  to  interpret 
these  cases  aright,  recognizing  the  fact  that  the  two  fistulse  were 
originally  but  one.  Fistulse  of  this  character  may  be  the  direct  result 
of  an  anterior  median  tear  produced  by  the  forceps. 

Vesico-vaginal  fistulse  vary  greatly  in  size  as  well  as  in  their  asso- 
ciated complications.  The  fistula  may  be  so  large  as  to  include  the 
whole  base  of  the  bladder.  On  examination,  the  upper  wall  of  the 
bladder,  red  and  easily  bleeding,  is  seen  hanging  down  into  the  vagi- 
na, looking  like  an  intense  inflamed  anterior  vaginal  wall,  often  more 
or  less  oedematous.  Other  fistulse  present  an  irregular  but  generally 
rounded  outline,  and  occuj^y  any  part  of  the  base  of  the  bladder; 
they  are  of  all  sizes,  down  to  an  opening  as  fine  as  a  hair. 

It  is  rare  that  a  woman  will  j)ass  through  a  difficult  labor,  result- 
ing in  fistula,  without  other  serious  injuries  to  the  lower  genital  tract. 
In  these  cases  we  often  meet  with  extensive  deposits  of  cicatricial  tissue 
in  the  vagina,  extremely  narrowed  cicatricial  vaginal  orifice,  distortion 
of  the  margins  of  the  fistula  by  the  vaginal  cicatrix,  and  the  pinning 
down  of  a  portion  of  the  fistula  to  one  of  the  pubic  rami  by  scar  tis- 
sue. A  patient  now  under  my  care  presented  a  complete  atresia  at  the 
vaginal  vault  with  retention  of  the  menstrual  secretions  in  the  uterus ; 
a  vesico-vaginal  fistula  lay  in  front  of  this  big  enough  to  admit  the 
thumb,  and  directly  opposite  the  vesico-vaginal  fistula,  on  the  pos- 
terior wall,  a  recto-vaginal  fistula  equally  as  large  was  found. 

The  diagnosis  of  vesico-vaginal  fistula  is  usually  easy.  There  is 
a  constant  discharge  of  urine,  although  the  operator  must  not  be 
misled  by  the  statement  of  the  patient  that  she  is  able  to  retain  it  for 
some  time  when  lying  down.  This  is  due  to  the  fact  that  a  vagina 
will  retain  considerable  urine  in  this  position.  The  urine  held  in 
this  way  escapes  on  arising,  but  the  patient  cannot  always  distin- 
guish between  such  a  mode  of  discharge  and  a  discharge  per  ure- 
tliram.  Upon  inspection  of  a  patient  with  a  large  fistula,  the  hole  in 
the  bladder  wall  is  very  conspicuous,  and  the  fact  of  the  communica- 
tion is  easily  demonstrated  by  a  sound  passed  through  the  urethra 
and  bladder  into  the  vagina.  A  smaller  fistula  may  be  more  diflicult 
to  find  and  may  require  the  aid  of  an  injection  into  the  bladder  of 
sterilized  milk,  which  will  then  be  seen  escaping,  drop  l)y  drop,  from 
the  minute  fistulous  orifice,  or  if  the  fistula  opens  into  the  uterus. 


714  KELLY — DISEASES   OF  THE   FEMALE   BLADDEE  AND  UEETHEA. 

from  the  cendx.  When  the  patient  is  placed  in  the  knee-breast  posi- 
tion, the  bladder  fills  with  air  and  its  walls  drop  away  from  the  fistula, 
through  which  a  large  part  of  the  bladder  can  be  inspected,  if  the 
opening  is  large.  Smaller  openings  examined  through  the  cystoscope 
introduced  per  urethram  are  often  difficult  to  detect  on  account  of 
their  lying  in  the  plane  of  vision.  When  located,  the  fistula  can  be 
made  to  appear  more  distinctly  by  pushing  up  the  bladder  wall  with 
the  end  of  the  speculum  and  bringing  the  opening  directly  across  it. 

Treatment. — Many  of  these  fistulse  occurring  post  partum  contract 
down  and  close  spontaneously.  We  are  in  a  position  to  appreciate 
the  ease  with  which  this  may  occur  in  uncomplicated  cases,  from  our 
experience  with  the  difficulties  in  keeping  open  a  fistula  created 
artificially  for  draining  the  bladder  for  cystitis. 

All  those  cases  which  do  not  close  spontaneously  call  for  operative 
treatment,  which  consists  by  one  device  or  another  in  uniting  the 
edges  of  the  bladder  in  such  a  manner  as  to  close  the  defect  with  the 
least  possible  tension  and  without  injury  to  the  ureters. 

It  is  not  long  since  Dr.  J.  Marion  Sims  closed  these  fistulfe  exclu- 
sively with  silver  sutures,  and  believed  that  the  success  in  their  treat- 
ment was  chiefly  due  to  the  special  form  of  suture  used.  Bozeman 
and  Emmet  have  laid  the  greatest  stress  upon  the  preliminary  prepa- 
ration of  complicated  cases,  by  incising  scar  tissue  and  dissipating 
it  by  pressure.  The  tendency  to-daj-,  however,  is  in  almost  all  cases 
to  proceed  at  once  with  the  repair  of  the  defect. 

Dr.  Nathan  Bozeman,  of  New  York  {New  York  Medical  Journal, 
Oct.  1st,  1887) ,  urges  the  use  of  hard  or  soft  dilators.  The  former  are 
introduced  and  left  in  the  vagina,  where  they  are  held  by  an  external 
attachment.  The  soft  dilators  are  made  of  strips  of  sponge  covered 
with  oiled  silk.  By  means  of  the  pressure  exercised  by  these  dilators 
scar  tissue  is  stretched  and  dissipated. 

In  all  cases  where  the  vagina  contains  necrotic  sloughing  tissue, 
where  the  edges  of  the  fistula  and  the  neighboring  parts  are  raw  and 
granulating,  and  where  incrustations  are  found  at  the  margins  of  the 
fistula  and  on  the  vaginal  walls,  these  complicating  conditions  must 
be  removed  before  proceeding  to  an  operation  for  closing  the  fistula. 
This  will  be  attained  by  exposing  the  parts  and  removing  as  much  of 
the  dead  tissue  and  incrustation  as  can  readily  be  taken  away,  and 
after  this  using  daily  warm  irrigations,  either  solutions  of  borax  or 
weak  carbolic-acid  lotions,  and  every  four  or  five  days  touching  the 
raw  surfaces  with  a  solution  of  nitrate  of  silver,  varying  in  strength 
from  three  to  five  per  cent. 

While  thus  treating  these  associated  conditions,  it  will  be  well 
also  to  incise  bands  of  scar  tissue  in  several  places,  loosening  up  the 


VESICO-VAGINAL   FISTULA.  715 

margins  of  the  fistula,  or  opening  up  tlie  vaginal  canal,  so  as  to  make 
the  fistula  more  accessible.  By  such,  preparations  a  difficult  ope- 
ration will  be  rendered  more  easy,  and  success  attained  where  the  re- 
sult of  an  immediate  operative  procedure  would  have  been  a  failure. 

1  hold,  however,  that  with  the  improved  technique  of  oar  opera- 
tions to-day,  the  same  amount  of  elaborate  preparation,  more  par- 
ticularly that  dealing  with  the  scar  tissue,  is  not  so  necessary  as  in 
«he  days  of  our  immediate  predecessors. 

A  skilful  operator  will  not  be  embarrassed  by  finding  a  marked 
(Stenosis  of  the  vaginal  orifice,  for  this  can  be  at  once  extensively 
divided  with  the  knife,  on  one  or  both  sides,  carrying  the  incision 
down  beside  the  rectum,  giving  all  the  room  necessary  to  get  at  the 
fistula.  Scar  tissue  radiating  out  from  the  edges  of  the  fistula  can 
also  at  the  time  of  operation  be  freely  incised,  or  even  cut  out  entirely, 
with  the  result  of  loosening  up  the  margins  of  the  fistula  so  that  they 
can  be  approximated. 

In  one  of  my  cases,  the  edge  of  the  fistula  was  pinned  down  to 
the  left  descending  pubic  ramus  and  was  extremely  awkward  to  get 
at,  besides  leaving  no  room  for  applying  sutures  on  the  side  of  the 
scar.  I  overcame  this  difficulty  successfully  by  introducing  a  deli- 
cate sharp  lance  on  the  vulvar  surface  about  3  cm.  (1:^  in.)  distant, 
and  carrying  it  along  under  the  mucous  membrane  freed  in  this 
way  the  margin  of  the  fistula  from  the  bone  without  puncturing  it. 
The  hemorrhage  from  the  little  opening  made  by  the  lance  gave  no 
trouble.     The  fistula  was  then  successfully  closed. 

Where  the  fistula  is  of  moderate  size,  2  cm.  in  diameter  or  smaller, 
and  its  edges  can  be  approximated  by  traction,  the  best  plan  of  pro- 
cedure is  a  denudation  of  its  margins  on  all  sides  bevelled  from  the 
vaginal  surface  down  to  the  mucosa  of  the  bladder.  It  is  not  neces- 
sary to  remove  more  than  the  very  edge  of  the  mucous  membrane. 
On  the  vaginal  surface,  however,  the  denudation  must  be  from  5  to  6 
or  8  mm.  in  width.     If  the  fistula  is  small  and  round,  not  more  than 

2  mm.  in  diameter,  the  denuded  surface  has  a  distinctly  funnel 
shape.  When  the  fistula  is  larger  the  denudation  simply  exaggerates 
the  shape  of  the  fistula. 

The  sutures  must  be  passed  in  such  a  manner  as  to  bring  the  mar- 
gins of  the  fistula  snugly  together  with  the  least  possible  resistance. 
In  general,  it  is  easier  to  imW  the  upper  part  of  the  vagina  down  into 
apposition  with  the  lower  part  than  to  attempt  to  make  up  a  large 
defect  by  x)ulling  together  the  wound  surfaces  from  side  to  side. 

Too  great  care  cannot  be  observed  throughout  to  avoid  catching 
the  ends  of  the  ureters  in  the  sutures.  The  consequence  of  such  an 
accident  is  uraemia.     If  the  symptoms  of  such  a  condition  were  dis- 


716  KELLY — DISEASES   OP   THE   FEMALE   BLADDEE   AND   UEETHKA. 

covered  in  time  the  sutures  would  liave  to  be  cut  immediately.  Such 
an  accident  may  be  guarded  against  by  carefully  locating  the  position 
of  the  ureteral  orifices,  and  also  by  not  passing  sutures  too  deeply  so 
as  to  include  too  much  tissue. 

For  the  smaller  fistulse  either  silk  or  silkworm-giit  sutures  may 
be  used ;  for  the  larger  the  best  sutures  are  deep  silkworm-gut,  with 
superficial  silk  sutures  between  them. 

The  easiest  way  to  pass  the  sutures  is  by  a  needle  threaded  with 
a  carrier.  The  needle  is  entered  about  3  mm.  from  the  margin  of  the 
wound  on  the  vaginal  surface,  and  brought  out  on  the  vesical  margin 
without  penetrating  the  mucosa ;  it  is  re-entered  on  the  opposite  side 
on  the  vesical  margin,  and  brought  out  again  on  the  vaginal  surface. 
After  several  sutures  have  been  introduced  in  this  way,  about  5  mm. 
apart,  they  may  be  tied,  and  others  introduced  in  the  same  way  and 
tied,  and  so  on  until  the  whole  fistula  is  closed.  It  is  not  necessary 
to  tie  them  very  tightly.  Each  suture  should  bring  the  margins  of 
the  wound  neatly  and  snugly  together.  Between  these  deeper  su- 
tures superficial  sutures  of  finer  silk  are  passed  for  accurate  approxi- 
mation on  the  surface.  An  iodoform  gauze  pack  is  now  p)laced  in  the 
vagina  and  a  soft  catheter  laid  in  the  bladder  through  the  urethra  to 
drain  the  urine  for  the  first  five  days.  To  avoid  irritation  from  the 
catheter,  it  is  better  to  leave  it  out  for  a  while  in  the  morning  and 
again  in  the  evening.  After  the  fifth  day,  the  patient  may  be  cathe- 
terized  every  three  or  four  hours  for  three  days  longer,  after  which 
she  may  void  urine.  The  stitches  may  be  removed  from  the  fifth  to 
the  tenth  day. 

Ability  to  retain  a  quantity  of  urine  always  increases  as  the  blad- 
der grows  accustomed  to  resuming  its  functions. 

I  have  ventured  with  success  in  some  of  the  smallest  fistulee  to  dis- 
pense entirely  with  the  use  of  the  catheter,  and  to  allow  the  patients 
from  the  first  to  empty  the  bladder  when  they  felt  the  inclination. 

Dr.  A.  Martin,  of  Berlin  [Zeitschrift  fur  Gynakologie,  1891),  de- 
scribes a  method  of  healing  a  large  fistula  after  numerous  other  at- 
tempts had  failed,  by  dissecting  a  flaj)  off  from  the  vagina  and  filling 
out  the  defect  with  that. 

Prof.  H.  Fritsch,  of  Breslau  {Centralhlatt  far  Gyndkologie,  1888, 
No.  49) ,  recommends  a  flap  method  of  closing  fistulse  by  splitting  the 
margins  of  the  wound  enlarged  by  an  incision  passing  through  the 
centre  of  the  fistula  and  for  some  distance  beyond  on  either  side. 
When  the  fistula  is  small,  the  fistulous  tract  itself  must  be  dissected 
out  in  such  a  way  as  not  to  make  the  wound  margins  uneven.  He 
looks  upon  the  method  as  especially  serviceable  where  the  fistula  is 
attached  to  the  bone. 


VESICO-VAGINAL  FISTULA.  717 

One  of  the  most  remarkable  operations  for  large  resico-vaginal 
fistula  was  tliat  performed  by  Dr.  E.  C.  Dudley,  of  Chicago,  upon  a 
woman  who  had  lost  so  much  of  the  base  of  the  bladder  with  the  an- 
terior vaginal  wall,  that  it  was  impossible  to  close  the  fistula  in  the 
ordinary  way.  Dr.  Dudley  completely  relieved  the  woman  by  one 
operation,  in  which  he  freshened  a  strip  on  the  mucosa  encircling  the 
inside  of  the  bladder.  He  then  folded  this  line  of  denudation  on  it- 
self and  sutured  with  silver  wire,  in  such  a  way  as  to  divide  the 
bladder  into  two  parts,  an  upper  closed  sac  communicating  with 
the  urethra  and  receiving  the  urine  from  the  ureters,  and  a  lower 
open  portion,  replacing  the  anterior  vaginal  wall. 

The  following  plan  for  the  treatment  of  the  larger  vesico-vaginal 
fistulaa  has  been  recommended  by  A.  Mackenrodt  of  Berlin  {Central- 
blatt  fur  Gynakologie,  No.  8,  1894) .  The  cervix  and  the  urethral 
prominence  in  the  vagina,  the  upper  and  lower  limits  of  the  fistula 
when  it  extends  so  far,  are  caught  by  bullet  forceps,  and  the  anterior 
vaginal  wall  is  put  on  the  stretch  by  traction  upward  and  downward 
by  the  forceps.  If  the  uterus  is  prevented  from  coming  down,  the 
scar  tissue  holding  it  back  is  cut  through.  An  incision  is  now  made 
through  the  tense  anterior  vaginal  wall  from  urethra  to  cervix,  pass- 
ing through  the  fistula.  The  edge  of  the  fistula  is  now  split  on  all 
sides  and  the  anterior  vaginal  wall  freed  from  the  bladder.  The  blad- 
der is  also  separated  from  the  uterus  high  up,  so  as  to  release  the 
wall  of  the  bladder  as  far  as  possible  in  front  and  behind.  The 
margin  of  the  fistula  opening  in  the  bladder  is  now  freshened  on  all 
sides  and  united  with  fine  silkworm-gut  sutures  close  together.  Over 
this  layer  of  sutures  a  second  and  even  a  third  layer  may  be  passed, 
turning  the  bladder  wall  in  upon  itself. 

After  thus  completely  closing  the  bladder,  the  opening  into  the 
vagina  is  denuded  and  the  body  of  the  uterus  pulled  down  (as  in  the 
operation  for  vaginal  fixation)  and  attached  to  the  anterior  vaginal 
wall,  the  vaginal  margins  being  brought  together  as  completely  as  the 
defect  will  allow.  Where  approximation  is  impossible  the  uterus  is 
united  to  the  sides  by  a  number  of  interrupted  sutures. 

Dittel  has  recommended  {Wiener  Minische  Wochenschrift,  1893, 
No.  25),  as  a  method  of  closure  in  difiicult  cases,  an  incision  through 
the  abdominal  wall  exposing  the  vesico-uterine  pouch,  a  transverse 
incision  freeing  the  bladder  from  the  uterus  and  then  from  the  vagina, 
until  the  fistula  is  exposed.  The  hole  in  the  bladder  is  now  sewed 
up,  the  peritoneal  surfaces  again  united,  and  the  abdomen  closed. 
The  opening  in  the  vaginal  wall  is  not  closed  but  drained  by  means  of 
a  strip  of  iodoform  gauze. 

The  closure  of  vesico-vaginal  fistulas  by  buried  sutures  was  recom- 


718  KELLY — DISEASES   OF   THE   FEMALE   BLADDER   AND    URETHEA. 

mended  by  VuUiet,  in  Geneva  {Nouvelles  Archives  d'  Ohstetrique  et  de 
Gynecologie,  1887,  Nov.  25tli) ,  and  practised  in  a  case  where  a  patient 
liad  been  alread}^  three  times  operated  upon.  The  margins  of  the 
bladder  wound  were  denuded  and  united  with  a  continous  suture, 
after  which  the  vaginal  surfaces  of  the  wound  were  brought  together 
in  like  manner.     The  sutures  used  were  of  silk. 

Where  the  fistula  lies  close  to  the  cervix,  it  may  readily  be  closed 
by  making  the  area  of  demidation  include  as  much  of  the  cervical 
tissue,  as  well  as  of  the  neighboring  vaginal  tissue,  as  may  be  neces- 
sary to  secure  broad  surfaces  of  approximation. 

Where  there  is  much  scar  tissue  about  the  cervix,  or  where  the 
fistula  opens  into  the  uterus  above,  the  best  plan  is  to  dissect  the 
vaginal  vault  free  from  the  anterior  part  of  the  cervix  and  to  carry 
the  dissection  up  high  enough  to  release  the  fistula  entirely  from 
its  uterine  connections,  and  leave  a  broad  margin  of  freshened  tissue 
surrounding  it  on  all  sides.  The  fistula  may  now  be  closed  with 
buried  sutures  of  fine  silk,  catgut,  or  silkworm-gut.  The  wound 
surface  between  the  bladder  and  uterus  may  now  either  be  closed  by 
sutures  or  drained  by  iodoform  gauze.  In  one  case  of  my  own,  where 
there  was  a  small  vesico-vaginal  fistula  just  in  front  of  the  cervix  and 
a  vesico-uterine  fistula  about  li  cm.  above  the  vault,  I  closed  both  by 
the  following  procedure :  The  cervix  was  caught  by  a  pair  of  bullet 
forceps  and  drawn  down,  making  the  vaginal  vault  tense.  The  vagina 
was  then  dissected  free  from  the  cervix  anteriorly,  and  the  dissection 
was  carried  above  the  vault  until  the  vesico-uterine  fistula  was  ex- 
posed and  severed  from  its  uterine  connection  for  about  1  cm.  on  all 
sides.  The  margins  of  the  vesico-vaginal  fistula  were  then  denuded. 
The  sutures  were  now  passed  in  such  a  manner  as  to  oppose  the 
fistulous  orifices  one  to  the  other,  so  that  with  a  single  row  of  su- 
tures from  side  to  side  both  fistulse  were  closed. 

Ureteral  Fistulse. 

Apart  from  the  conditions  already  described,  a  stillicidium  of  urine 
from  the  genitals  may  be  seen  when  there  is  an  abnormal  communi- 
cation between  one  of  the  ureters  and  some  portion  of  the  genital 
tract.  The  striking  peculiarity  of  these  cases  is,  that,  in  spite  of  the 
constant  leakage,  urine  is  passed  at  regular  intervals  ^er  vias  natu- 
rales.  This  is  due  to  the  fact  that  while  one  ureter  is  abnormally 
switched  off  into  the  interior  genital  tract,  its  fellow  still  retains  in- 
tact its  connection  with  the  bladder. 

Ureteral  fistulse  are  observed  as  congenital  malformations,  in  con- 
sequence of  injuries  during  labor,  from  operations  about  the  vaginal 


URETERAL  FISTULiE.  719 

vault,  sucli  as  the  incising  of  an  abscess,  and  after  the  operation  of 
vaginal  hysterectomy.  These  fistulae  in  the  past  were  quite  rare,  but 
they  have  within  recent  years  become  much  more  common  because  of 
the  great  frequency  with  which  the  uterus  is  removed  by  the  vagina 
for  cancerous  disease.  The  explanation  of  this  fact  is  that  the  infil- 
tration of  the  cervix  with  the  new  growth  makes  it  much  larger,  and 
shortens  the  distance  between  the  cervix  and  pelvic  wall,  conse- 
quently bringing  the  ureter,  which  lies  between,  much  closer  to  it. 
On  the  other  hand,  also,  the  necessity  of  leaving  a  pedicle,  and  the 
natural  anxiety  of  the  operator  to  give  the  disease  as  wide  a  berth  as 
possible,  make  it  remarkable  that  the  ureter  is  not  more  frequently 
involved  than  it  appears  to. be  from  published  reports. 

The  diagnosis  of  ureteral  fistula  will  be  made  by  noting :  first,  that 
although  there  is  a  constant  escape  of  urine,  the  patient  still  passes 
urine  at  regular  intervals;  second,  that  upon  injection  of  sterilized 
milk  into  the  bladder  none  of  it  escapes  through  the  vagina,  while 
the  urine  still  escaping  from  the  vagina  continues  clear ;  third,  that 
by  placing  the  patient  in  the  dorsal  position  with  elevated  pelvis,  or 
in  the  knee-breast  position,  the  ureters  may  be  catheterized  as  de- 
scribed, and  urine  collected  from  one  side  while  no  urine  escapes 
from  the  other;  fourth,  that  the  sound  may  be  readily  entered  into 
one  ureter  and  passed  back  to  the  posterior  wall  of  the  pelvis,  while 
in  the  other  it  cannot  be  pushed  in  more  than  a  few  centimetres ; 
fifth,  in  the  congenital  malformation  where  there  is  a  double  ure- 
ter on  one  side  with  one  of  its  openings  near  the  urethra,  and  the 
other  in  the  bladder,  the  evidence  that  the  fistula  is  not  vesical  will 
be  obtained  by  the  injection  of  milk.  The  catheterization  of  both 
ureters  will  demonstrate  also  that  they  are  pervious  and  functionally 
active.  It  may  also  be  possible  to  pass  a  bougie  into  the  abnormal 
orifice  and  push  it  up  through  the  pelvis  behind  the  abdominal 
cavity. 

The  treatment  of  ureteral  fistula  is  by  turning  the  abnormal  ori- 
fice into  the  bladder  by  either  a  vaginal  or  an  abdominal  operation. 
Where  there  is  sufficient  room  to  work  in  the  vagina,  and  the  ureter 
is  long  enough  to  be  dissected  out  and  turned  in  through  a  slit  made 
in  the  base  or  posterior  wall  of  the  bladder,  the  vaginal  route  is  to 
be  preferred.  If,  on  the  contrary,  the  fistula  is  up  in  the  uterus  or  is 
hidden  behind  scar  tissue  of  the  vaginal  vault,  the  better  plan  will 
be  to  oi)en  the  abdomen  and  dissect  the  lower  3  or  4  cm.  (1  or  1^  in.) 
of  the  ureter  loose  from  its  attachments.  Then  sew  the  ureter  into 
the  small  opening  made  into  the  bladder  at  the  nearest  point,  with  a 
series  of  delicate  circular  sutures.  The  ureter  thus  attached  must 
I^roject  a  slight  distance  into  the  cavity  of  the  bladder. 


720  KELLY — DISEASES    OE   THE   FEMALE   BLADDER  AND   URETHRA. 

I  performed  this  operation  in  the  fall  of  1894,  upon  a  woman  wlio 
had  been  operated  upon  by  my  assistant  some  weeks  before,  for  cancer 
of  the  cervix.  The  right  ureter  had  been  cut  off  in  the  operation,  and 
was  draining  through  the  scar  tissue  into  the  vaginal  vault.  After 
demonstrating  on  which  side  the  injury  lay,  by  the  cystoscopic  ex- 
amination and  the  sound,  the  abdomen  was  opened,  and  the  ureter  dis- 
sected out  of  its  bed.  The  ureter  thus  lifted  up  was  too  short  to  reach 
the  bladder,  w^hich  was  therefore  dissected  loose  from  its  pelvic  wall 
attachments,  anteriorly  and  laterally  and  dropped  back  to  the  ureter. 
The  ureter  was  then  sutured  into  a  small  opening  made  in  the  poste- 
rior vesical  wall.  To  avoid  tension  upon  the  bladder,  in  closing  the 
abdomen  the  lower  part  of  the  peritoneal  incision  was  not  drawn  to- 
gether. The  abdominal  wall  was  closed  throughout.  The  operation 
was  rendered  difficult  throughout  by  the  obesity  of  the  patient,  but 
immediate  union  was  obtained  and  the  urine  thereafter  was  dis- 
charged normally  per  urethram. 

Stone  in  the  Bladder. 

Calculi  in  the  female  bladder  arising,  as  in  the  male,  simply  from 
a  deposit  of  the  salts  in  the  urine  without  other  provocative  cause, 
are  but  rarely  found.  Numerous  cases,  however,  are  recorded  in 
which  foreign  bodies  introduced  by  the  patient  herself  through  the 
urethra,  or  by  a  surgeon  in  the  course  of  an  operation,  form  the  basis 
of  calculi  which  may  attain  considerable  size.  All  sorts  of  objects 
small  enough  to  slip  into  the  urethra  have  been  thus  introduced,  and 
afterward  found  forming  the  nuclei  of  calculi.  The  commonest  are 
catheters,  pencils,  and  hair-pins.  Of  the  latter  a  number  of  cases 
are  recorded.  The  hairs  of  a  dermoid  cyst  may  also  form  the  nucleus 
of  a  calculus. 

An  example  of  a  hair-pin  calculus  is  shown  in  Fig.  89.  This  was 
introduced  by  the  patient,  a  young  unmarried  woman,  who  married 
a  short  time  afterward.  She  passed  through  a  confinement  without 
any  injury  to  the  bladder,  although  the  calculus  had  already  formed 
about  the  pin  and  was  felt  by  the  doctor  in  attendance,  who  pushed 
it  up  into  the  abdomen  while  the  head  was  descending  through  the' 
pelvis.  No  explanation  could  be  obtained  from  the  patient  as  to  how 
the  hairpin  got  into  the  bladder,  but  the  mother,  who  saw  it  after  re- 
moval, declared  that  she  must  have  swallowed  it. 

I  have  twice  removed  calculi  forming  about  sutures  left  in  the 
septum  after  an  operation  for  vesico-vaginal  fistula.  The  peculiarity 
of  these  stones  is  that  they  are  fixed. 

The  symptoms  of  vesical  calculus  are  painful  micturition  and  the 
various  symptoms  of  the  cystitis  excited  by  its  presence. 


STONE   IN  THE  BLADDER. 


721 


The  diagnosis  is  made  by  inspection,  when  the  calculus  will  be 
readily  seen  either  lying  free  or  pocketed  in  the  bladder.  It  may 
also  be  recognized  by  the  sound  striking  a  hard  body,  and  biman- 
ually  by  catching  the  stone  between  the  fingers  in  the  vagina  and  the 
hand  pressing  down  through  the  abdominal  wall  into  the  pelvis.  All 
methods  of  examination,  however,  are  inferior  to  direct  inspection 
after  the  manner  described  above. 

The  treatment  of  stone  is  by  removal  in  one  of  the  following  ways : 
If  it  is  quite  small,  not  more  than  2  to  2^  cm.  in  diameter,  or  if  it  is 
somewhat  larger  than  this,  and 
quite  soft,  it  may  be  crushed 
with  a  lithotriptor  introduced 
into  the  bladder  filled  with  water 
and  with  the  pelvis  elevated. 

The  old  method  of  dilating 
the  urethra  and  dragging  out  the 
stone  ought  never  to  be  resorted 
to  for  the  extraction  of  rough 
stones  or  those  exceeding  1^  to 
2  cm.  (f  to  f  in.)  in  diameter. 

Where  the  stone  cannot  be 
safely  removed  through  the  ure- 
thra in  the  manner  described, 
the  best  avenue  of  approach  to 
it  is  by  an  incision  into  the  base 
of  the  bladder  in  the  median  line 
in  front  of  the  cervix.  This  in- 
cision can  be  made  from  an  inch 
to  an  inch  and  a  half  long,  the 
stone  removed  through  it,  and 
the  incision  immediately  closed 
again. 

Where  the  stone  is  so  large 
as  to  fill  the  bladder,  being  5  or 
6  cm.  (2  or  2-j  in.)  in  diametei?, 
or  even  larger,  and  the  patient 
is  in  good  condition,  it  will  often  be  better  to  remove  it  by  a  supra- 
pubic oj^eration,  making  an  incision  into  the  abdominal  wall  in  the 
median  line  just  above  the  symphysis,  pushing  up  the  peritoneum 
without  opening  it,  incising  the  bladder,  and  removing  the  stone. 
If  there  is  much  cystitis,  it  will  be  better  not  to  close  the  wound 
entirely,  but  to  suture  the  bladder  wound  and  insert  a  gauze  drain 
above  this  in  case  of  infection  and  breaking  down  of  the  incision. 
Vol.  I.— 46 


Fig.  89.— Dr.  Eccles'  Case  of  Hairpin  Calculus. 


722  KELLY — DISEASES   GF   THE   FEMALE   BLADDER  AND   URETHRA. 

Cystitis. 

It  is  impossible  at  present  to  estimate  the  frequency  with,  which 
cystitis  occurs  in  women.  Severer  grades  of  cystitis  are  not  infre- 
quently met  with,  and  milder  degrees  of  the  affection  seem  to  become 
more  frequent  as  cases  are  examined  b}^  the  new  cystoscopic  method. 

All  grades  of  inflammation  of  the  bladder  mucosa  are  found,  from 
a  slight  hj^persemia  well  localized,  through  hypersemic  conditions 
distributed  in  patches  over  the  surface  of  the  bladder,  to  an  intense 
inflammatory  state  involving  the  whole  surface  of  the  mucosa. 
While  we  cannot  properly  speak  of  the  hypersemias  as  inflammatory 
clinically,  we  observe  all  grades  of  them  from  a  mild  congestion  to  a 
well-defined  inflammation. 

The  cause  of  the  inflammation  is  one  of  the  pus-producing  organ- 
isms, or  it  may  be  a  diphtheritic  affection,  or  tuberculosis.  Affections 
of  the  latter  class  have  proven,  in  my  experience,  to  be  quite  com- 
mon. In  several  instances,  the  tubercular  cystitis  was  associated  with 
a  tubercular  ureteritis.  In  another  case  a  tubercular  inflammation 
was  localized  near  the  right  posterior  cornu  of  the  bladder.  I  was 
able  here  to  discover  by  a  cystoscopic  examination  that  the  focus  of 
the  bladder  trouble  was  about  a  small  orifice  which  a  careful  biman- 
ual pelvic  examination  showed  to  be  connected  with  a  densely  adhe- 
rent right  tube  and  ovary,  undoubtedly  tubercular,  and  pouring  pus 
through  a  sinus  under  the  broad  ligament  into  the  bladder. 

Morhid  Anatomy. — The  changes  in  cystitis  are  quite  characteristic, 
the  most  marked  being  the  reddening  of  the  surface,  more  or  less  in- 
tense according  to  the  grade  of  inflammation,  and  varying  in  degree 
with  the  extent  of  contraction  of  the  bladder.  As  the  inflammation 
becomes  more  marked  the  larger  vessels,  so  characteristic  of  the  nor- 
mal background,  disappear  from  view.  Sometimes  a  network  of  in- 
numerable capillaries  may  be  seen,  at  others  nothing  more  than 
an  intense  red  blush  on  the  surface.  In  a  graver  class  of  cases  the 
mucous  membrane  breaks  down  in  places  and  discharges  in  flabby 
shreds  mixed  with  pus.  These  can  be  seen  hanging  from  the  sides 
of  the  bladder,  overlying  areas  of  granulation  tissue,  floating  in  a 
little  bloody  urine,  accumulating  in  the  vault  (when  the  patient  is 
examined  in  the  knee-breast  position) ,  and  hanging  from  superior  to 
inferior  wall  like  beans.  In  these  cases,  to  get  a  clear  picture  of  the 
actual  state  of  the  bladder,  it  will  be  necessary  to  introduce  a  two- 
way  catheter  and  to  give  it  a  thorough  washing  out.  Oftentimes  the 
bladder  walls  are  so  coated  with  a  deposit  of  dark  blood  as  to  be  in- 
visible. This  may  come  down  from  the  kidneys  and  settle  on  the 
mucous  membrane,  or  may  arise  from  hemorrhage  of  the  bladder 


CYSTITIS.  723 

wall.  It  is  usually  found  in  those  parts  of  the  bladder  which  are 
most  dependent  when  the  patient  is  lying  down  or  sitting.  A  little 
pledget  of  cotton  introduced  on  the  mousetooth-forceps  will  remove 
the  thin  layer  of  blood  and  expose  the  surface  beneath  it. 

At  the  first  examination  of  a  case  of  cystitis,  it  is  in  the  highest 
degree  important  to  make  a  minute  inspection  of  every  part  of  the 
bladder,  not  forgetting  the  urethra,  when  the  speculum  is  withdrawn 
at  the  conclusion  of  the  examination.  Particular  attention  must  be 
paid  to  the  ureteral  areas.  The  results  of  the  examination  should 
also  be  entered  upon  the  schemata  which  I  have  described  in  the 
section  on  the  topography  of  the  bladder. 

The  treatment  of  cystitis  is  general,  systemic,  and  local.  Patients 
thus  afflicted  should  go  to  bed  and  keep  as  quiet  as  possible.  The 
bowels  must  be  kept  thoroughly  open,  and  a  mild,  non-stimulating 
diet  prescribed.  Sweet  spirit  of  nitre  given  in  half-teaspoonful 
doses,  four  to  six  times  daily,  often  diminishes  the  pain.  Hot  vagi- 
nal injections  are  serviceable  as  a  counter-irritant,  and  benefit  is  often 
derived  by  the  use  of  hot- water  bags  over  the  abdomen.  The  most 
direct  and  best  form  of  local  treatment  is  by  injections  of  a  few 
ounces  of  1-100,000  bichloride  solution  repeated  daily.  While  the 
patient  at  first  is  able  to  retain  only  a  few  ounces,  she  will  often  soon 
be  able  to  hold  four  or  five.  The  strength  of  the  solution  can  be 
increased  by  taking  off  5,000  each  time,  until  it  is  equal  to  1-20,000 
or  1-30,000.  "Where  the  bichloride  is  not  well  tolerated,  a  good  re- 
sult may  often  be  obtained  by  injections  of  a  saturated  solution  of 
borax  in  water,  once  daily. 

Where  the  cystitis  is  localized  in  patches,  the  improvement  will 
often  be  hastened  by  applications  once  in  five  days,  or  once  a  week, 
of  a  three-,  five-,  or  even  ten-per-cent.  solution  of  nitrate  of  silver, 
directly  upon  the  affected  area.  This  application  must  of  course 
be  made  through  the  cystoscope,  and  be  controlled  by  sight.  It  will 
not  do  good,  but  rather  harm,  where  the  inflammation  is  widespread 
and  intense. 

When  the  disease  has  existed  a  long  time,  and  the  patient  is  suf- 
fering intensely,  and  the  whole  or  almost  all  the  bladder  is  found  to 
be  affected,  immediate  relief  will  be  given  and  a  cure  more  quickly 
realized,  by  making  an  opening  an  inch  long  into  the  vagina  through 
the  base  of  the  bladder,  and  suturing  the  vesical  to  the  vaginal  mu- 
cosa, to  prevent  the  artificial  fistula  from  closing  too  soon.  The  con- 
stant, perfect  drainage  thus  secured  will  give  great  relief,  and  in  the 
course  of  from  two  to  four  months  will  bring  about  such  a  degree  of 
imy)rovement  tliat  the  fistula  may  be  closed  and  the  rest  of  the  cure 
effected  by  irrigation. 


724  KELLY — DISEASES  OP  THE  FEMALE  BLADDER  KNB  URETHRA. 

EXFOLLVTIVE   CySTITIS. 

An  exfoliation  of  tlie  entire  mucous  with  more  or  less  of  tlie  mus- 
cular membrane  of  tlie  bladder  lias  been  observed  in  cases  of  the  re- 
troflesed  gravid  uterus,  usually  at  about  the  fourth  month.  The 
same  accident  has  been  noted  after  delivery  at  term  and  after  lifting 
a  heavy  weight.  In  one  of  my  own  cases  it  occurred  in  a  girl  of 
about  twenty  years  after  the  removal  of  a  large,  densely  adherent 
monocystic  ovarian  tumor. 

The  disease  begins  with  pain,  elevation  of  temperature,  the  dis- 
charge of  fetid  ammoniacal  urine,  often  with  considerable  blood  and 
pus.  The  loosened  membrane  may  choke  the  internal  urethral  orifice, 
causing  temporary  retention  followed  by  the  sudden  expulsion  of  a 
large  amount  of  urine. 

The  membrane  is  often  thrust  out  through  the  urethra  entire  or  in 
pieces  consisting  of  a  discolored  mucosa  with  shreds  or  sheets  of  the 
muscularis  and  more  or  less  covered  with  crystals  of  urine  salts.  In 
spite  of  the  serious  nature  of  the  ailment  recovery  with  powers  of 
retention  of  the  urine  occurs  in  a  large  percentage  of  the  cases.  (See 
article  by  Dr.  Boldt  in  the  American  Journal  of  Obstetrics,  Vol.  XXL, 
p.  350 ;  also  one  F.  W.  N.  Haultain  in  the  Edinburgh  Medical  Journal, 
June,  1890.) 

HvPERiEMLi   OF   THE   VESICAL   TrIANGLE. 

I  have  thus  far  invariably  found,  in  cases  of  so-called  irritable  blad- 
der, where,  with  more  or  less  pain,  the  patient  has  been  distressed 
with  frequent  micturition  during  the  day,  and  sometimes  by  night 
also,  that  there  exists  over  the  whole  or  some  part  of  the  vesical  tri- 
angle a  marked  hypersemia.  As  a  rule,  this  is  not  uniform  but  dis- 
tributed in  a  patch  nearer  to  one  ureter.  It  may  be  located  near  the 
urethral  orifice  and  extend  for  a  short  distance  down  into  the  ure- 
thra. I  have  invariably  found  this  condition  in  patients  troubled 
with  their  bladders  after  an  abdominal  operation.  A  young  girl  was 
sent  to  me  from  the  South  suffering  from  no  other  complaint  than 
frequent  micturition.  On  examining  her  I  found  the  whole  bladder 
was  sound  except  this  area,  where  the  hypersemia  was  very  marked. 
The  patient  was  entirely  and  permanently  relieved  by  a  few  treat- 
ments with  a  three-per-cent.  solution  of  nitrate  of  silver,  directly  ap- 
plied, through  the  endoscope,  on  a  piece  of  cotton.  By  this  simple 
means  of  treatment  I  have  been  able  to  relieve  all  cases  of  this  char- 
acter, thus  getting  rid  of  a  class  of  complainers  who  had  previously 
given  me  much  distress.  These  women  may  be  treated  as  office  pa- 
tients, and  allowed  to  return  home  immediatel}^  after  the  application, 
which  is  only  slightly  or  not  at  all  distressing. 


NEOPLASMS.  725 

Ulcer  of  the  Bladder. 

I  have  seen  two  cases  of  simple,  well-defined  ulcer  of  the  bladder, 
located  in  each  instance  in  the  triangle  between  the  ureters  and  ure- 
thra. One  of  these  patients,  a  stout,  well-built  woman,  was  pro- 
foundly ansemic,  from  excessive  vesical  hemorrhages.  She  had  for 
some  months  been  constantly  passing  large  quantities  of  blood  during 
micturition.  The  cystoscopic  examination  showed  an  oval  ulcer 
with  a  raw,  ragged,  bleeding  surface  stretching  transversely  across 
the  triangle.  A  few  treatments  with  nitrate  of  silver  checked  the 
hemorrhages  entirely  and  brought  about  a  complete  recovery.  There 
has  been  no  relapse  after  almost  a  year. 

In  the  second  case,  at  the  apex  of  the  triangle  immediately  within 
the  urethra,  I  found,  in  a  stout,  healthy-looking  woman,  a  shining 
white  "diphtheritic"  patch  about  8  mm.  in  diameter,  with  thick 
turned-up  edges.  This  was  readily  removed  from  a  flat  pinkish  base, 
which  bled  easily  but  not  excessively ;  immediately  surrounding  the 
ulcer,  the  mucous  membrane  was  deeply  injected  and  oedematous,  and 
projected  over  its  edges.  The  patient  complained  of  painful,  fre- 
quent micturition.  Under  treatment  with  a  solution  of  nitrate  of  sil- 
ver, at  first  five  and  afterward  three  per  cent. ,  carefully  limited  to  the 
diseased  area,  the  diphtheritic  membrane  has  disappeared  entirely 
and  the  ulcer  has  contracted  down  to  2  mm.  in  diameter. 

Neoplasms. 

Cancer  of  the  bladder  is  often  observed  through  extension  of  the 
disease  from  the  cervix  uteri,  but  primary  new  growths  of  the  blad- 
der walls  are  rare. 

The  relative  frequency  of  tumors  in  the  male  and  female  affecting 
the  bladder  walls  primarily  has  been  estimated  in  the  proj)ortion  of 
three  to  one. 

Williams  {British  Medical  Journal,  1889)  found,  out  of  90  cases 
of  tumor  of  the  bladder,  of  which  20  were  in  women,  16  were  carcino- 
mata,  2  papillomata,  1  sarcoma,  and  1  fibroma. 

The  name  papilloma  is  often  made  to  include  both  benign  fibrous 
growths  covered  with  epithelium  more  or  less  branched  in  form,  and 
growths  which  show  their  malignant  nature  by  relapsing  into  carci- 
nomata  or  sarcomata. 

True  papilloma,  "dendritic  fibroma,"  appears  to  originate  from 
a  })udding  of  the  vesical  blood-vessels. 

Golding-Bird  (British  Medical  Journal,  1889)  describes  a  case 
of  sarcoma   originating   in  the   i)osterior  walls   of  the   bladder,  re- 


726  KELLY — DISEASES   OF  THE  FEMALE  BLADDER  AND   URETHRA. 

moved  by  suprapubic  section  with  the  galvano-caustic  loop.  The 
wound  was  drained  by  carbolized  gauze.  The  patient  died  on  the 
fourth  day,  with  infection. 

The  most  characteristic  symptom  of  bladder  tumors  in  the  early 
stages  is  hemorrhage. 

The  diagnosis  is  easily  made  upon  inspection  with  the  cystoscopy 

The  treatment  mil  vary  according  to  the  nature  and  size  of  the 
tumor.  Small  pedunculated  tumors  can  be  easily  caught  with  a  snare 
like  that  used  for  removing  nasal  polypi.  They  may  be  slowly  re- 
moved in  this  way,  taking  several  hours  if  the  operator  deem  it  wise 
on  account  of  the  danger  of  hemorrhage.  The  patient  is  returned  to 
bed  after  the  loop  of  the  snare  has  been  placed  about  the  pedicle ; 
the  screw  is  turned  to  tighten  it  up  every  ten  or  fifteen  minutes  until 
the  pedicle  is  cut  through.  Larger  tumors  may  be  removed  by  vagi- 
nal incision  in  the  same  manner  as  vesical  calculi.  The  base  may  be 
ligated  or  closed  by  sutures,  which  will  afterward  be  removed  through 
the  cystoscope. 

Malignant  tumors,  unless  limited  in  extent  and  so  situated  on  the 
base  of  the  bladder  as  to  be  readily  reached  through  the  vagina, 
ought  to  be  removed  by  preference  by  suprapubic  section,  through 
which  larger  areas  of  the  bladder  wall  can  be  extirpated  with  more 
precision,  and  the  incised  edges  brought  satisfactorily  together. 

Professor  Pawlik,  of  Prague  {Centralblatt  fiir  GynaJcologie,  1890, 
page  113) ,  removed  a  small  pedunculated  polypus  from  the  bladder  by 
a  vaginal  incision.  Eight  months  later  the  hemorrhages  had  returned, 
and  an  examination  revealed  an  extensive,  broad-based  papilloma, 
for  which  he  proceeded  to  extirpate  the  bladder.  After  introducing 
two  metal  catheters  into  the  ureters,  he  freed  the  terminal  extremity 
of  each  ureter  for  2  cm.,  and  attached  it  to  the  vaginal  wall,  establish- 
ing two  uretero-vaginal  fistulse.  Three  weeks  later  he  extirpated  the 
bladder  by  making  a  suprapubic  incision,  without  opening  the  peri- 
toneum, and  released  the  bladder  from  its  attachments.  The  vaginal 
wall  was  then  cut  transversely,  just  beyond  the  urethral  prominence, 
and  the  bladder  drawn  through  this  opening  into  the  vagina  and  cut  off 
at  the  internal  urethral  orifice.  An  attempt  was  now  made  to  close 
the  vagina  by  turning  the  urethra  into  it  and  making  a  pocket  for  the 
urine  escaping  from  the  ureters,  by  uniting  the  upper  margin  of  the 
vaginal  incision  to  the  anterior  urethral  wall  and  closing  the  vagina 
below  this  by  a  circular  denudation  and  suture.  The  new  bladder 
formed  in  this  way  had  a  capacity  of  400  c.c.  The  closure  of  the 
vagina,  however,  was  not  successful. 

The  most  important  summary  of  the  literature  of  this  subject  will 
be  found  in  the  Jahresberichte  of  Professor  Frommel,  of  Erlangen. 


INDEX  TO  VOLUME  I. 


Abscess,  renal,  704 

sub-urethral,  in  the  female,  705 
Adenoma,  renal,  108 
Albumin  and  hsemoglobin,   relationship 

between,  534 
Albuminuria,  26 

accidental,  615 

after  exertion,  29 

causes  of,  26 

dietetic,  28 

due  to  the  presence  of  blood  in  the 
urine,  616 

due  to  the  presence  of  chyle  in  the 
urine,  617 

due  to  the  presence  of  pus  in  the 
urine,  615 

extra-renal,  615 

from  serum  leakage,  617 

in  pyuria,  589 

in  renal  calculus,  144 

paroxysmal  or  cyclic,  27 

seminal,  617 

significance  of,  27 

simple  persistent,  29 

vesicular  false,  617 
Aphasia,  ursemic,  34 
Arterial  tension,  uraemic,  38 
Arteritis,  90 

relation  of,  to  diseases  of  the  kidneys, 
17 

Balanitis,  460 

treatment,  499 
Balano-posthitis,  460 

treatment,  499 
Bar  at  the  neck  of  the  bladder,  410 
Bartels'  classification  of  diseases  of  the 

kidneys,  13 
Bilharzia  hajmatobia,  264 
Bladder,  absence  of  the,  245 


Bladder,  absorption  test  of  abrasions  of 
the  mucosa,  534 
anatomy  of  the  female,  666 

Bladder  and  Urethra,  Female,  Dis- 
eases of  the,  663 
introductory,  663 ;  anatomy,  664 ; 
methods  of  examining  the  female 
urinary  organs,  671 ;  malformations 
of  the  urethra,  695;  displacements 
of  the  urethra,  696 ;  variations  in 
calibre  of  the  urethra,  698 ;  urethro- 
vaginal fistula,  702  ;  urethritis,  708 ; 
new  growths  of  the  urethra,  707 ; 
congenital  anomalies  of  the  blad- 
der, 709  ;  displacements  of  the  blad- 
der, 710  ;  vesico- vaginal  fistula,  712 ; 
ureteral  fistulge,  718 ;  stone  in  the 
bladder,  720  ;  cystitis,  722  ;  ulcer  of 
the  bladder,  725 ;  neoplasms  of  the 
bladder,  725 

Bladder,  atony  of  the,  249 

bar  at  the  neck  of  the,  410 
bilharzia  haematobia  in  the,  264 
cancer  of  the,  254 

hsematuria  in,  555 
in  the  female,  725 
congenital  anomalies  of,  in  the  fe- 
male, 709 
cysts  of  the,  255 

Bladder,  Diseases  of  the,  203 

rupture  and  injuries  of  the  bladder, 
203 ;  foreign  bodies  in  the  bladder, 
212 ;  inflammation  of  the  bladder, 
223 ;  malformations  and  structural 
alterations  in  the  form  of  the  bladder, 
245 ;  tumors  of  the  bladder,  252 ; 
tumors  of  the  prostate,  256  ;  endemic 
haematuria,  264 ;  sinuses  connected 
with  the  bladder,  269 ;  stone  in  the 
bladder,   278 ;  lithotrity  or  lithola- 


728 


IKDEX  TO   VOLUME   I. 


paxy,  284 ;  measures  employed  for 
the  removal  of  stone  from  the  blad- 
der other  than  by  crushing  alone, 
300 ;  suprapubic  cystotomy,  308 ; 
the  recurrence  of  stone  after  opera- 
tion, 314 ;  bibliographical  references, 
822 
Bladder,  displacements  of  the  female,  710 
double,  245 

in  the  female,  709 
drainage  of  the,  241 
ectopia  of  the  female,  711 
enchondroma  of  the,  255 
examination   of  the  female,   asepsis 

in,  693 
extroversion  of  the,  245 
fissure  of  the  anterior  wall  in  the 

female,  709 
foreign  bodies  in  the,  212 
Bladder,   Female,   Diseases  of  the, 

708 
congenital  anomalies,  709  ;  fissure  of 
the  anterior  wall,  709  ;  double  blad- 
der, 709  ;  displacements,  710  ;  ecto- 
pia without  fissure,  711  ;  vesico- 
vaginal fistula,  712  ;  ureteral  fistulae, 
718;  stone  in  the  bladder,  720; 
cystitis,  722 ;  hyperaemia  of  the 
vesical  triangle,  724 ;  ulcer,  725 ; 
neoplasms,  725 
Bladder,    haematuria  in  diseases  of  the, 

553,  570 
hemorrhage  from  the  base  of   the, 

537 
hernia  of  the,  247 
hypersemia  of  the  vesical  triangle  in 

the  female,  724 
hypertrophy  of  the,  248 
inflammation  of  the,  see  Cystitis 
inversion  of  the,  248 
Bladder,  Malformations  and  Struc- 
tural Alterations  est  the  Form 

OF   THE,  245 

absence,  245 ;  double,  245 ;  extro- 
version, 245  ;  patent  urachus,  247  ; 
hernia,  247  ;  inversion,  248  ;  hyper- 
trophy, 248  ;  atony,  249  ;  sacculation 
and  pouching,  249 ;  tumors,  252  ; 
tumors  of  the  prostate,  256 ;  treat- 
ment of  tumors  of  the  bladder  and 
prostate,  258 ;  cystoscopy,  260 


Bladder,   methods  of  examining  the  fe- 
male, 671 
myoma  of  the,  252 
myxoma  of  the,  252 
neoplasms  of  the  female,  725 
pain  in  the,  in  renal  disease,  576 
papilloma  of  the,  253 
in  the  female,  725 
perforation  of,  from  within,  218 
pouching  of  the,  251 
prolapse  of  the  female,  710 
rupture  of  the,  203 
sacculation  of  the,  249 
sarcoma  of  the,  252 
in  the  female,  725 
Bladder,    Sinuses    connected    with 
THE,  269 
vesico-intestinal,  269 ;    s.upra-pubic, 
274 ;  unclassified,   275  ;  vesico-vagi- 
nal,  275 ;  vesico-rectal,  276 
in  the  female,  712 
Bladder,  Stone  in  the,  278 

sounding    for,    278 ;    diagnosis    of, 
282 ;    treatment,    284 ;   lithotrity   or 
litholapaxy,    284;    lithotomy,    300; 
suprapubic  cystotomy,    308 ;  recur- 
rence of  stone  after  operation,  314 
haematuria  in,  558,  570 
in  the  female,  720 
Bladder,  suprapubic  puncture  of  the,  244 
suture  of  the,  206 
tapping  the,  through  the  enlarged 

prostate,  244 
toilet  of  the,  235 
topography  of  the  female,  668 
tuberculosis  of  the,   haematuria  in, 

573 
tumor  of  the,  252 

treatment  of,  258 
ulcer  of  the  female,  725 
villous  cancer,  so-called,  of  the,  253 
wounds  of  the,  203 
Blindness,  uraemic,  34 
Blood  in  the  urine,  22,  527  (see  Hmma- 

turia) 
Brain,  diseases  of  the,  phosphaturia  in, 

632 
Bright 's  disease,  3  (see  also  Kidney  Dis- 
eases of  the) 
acute,  45,  52,  62 

current  beliefs  concerning,  17 


INDEX   TO   VOLUME   I. 


729 


Bright's  disease,  chronic,  49,  69,  86 

current  beliefs  concerning,  17 

hsematuria  in,  550 

IDolyuria  in,  643 

treatment  of  baematuria  in,  581 
Bubo,  459 

treatment,  498 

Calculus,  cystine,  619 
prostatic,  397 

Calculus,  Renal,  137 

varieties,  138  ;  formation,  137  ;  pliy- 
sical  characters,  142 ;  symptoms, 
143  ;  diagnosis,  144  ;  treatment,  146 
differential  diagnosis  of,  from  tuber- 
culosis, 566 

hsematuria  in,  552,  561 
pyelitis  following,  601 

Calculus,  urethral,  in  the  female,  707 
vesical,  278 

hsematuria  in,  558,  570 
in  the  female,  720 

Cancer  of  the  bladder,  254 
hffimaturia  in,  555 
in  the  female,  735 
of  the  kidney,  107,  170 
haematuria  in,  546,  568 
treatment  of  hsematuria  from,  580 
of  the  prostate,  256,  396 
of  the  ureters,  193 
of  the  urethra  in  the  female,  708 
so-called  villous,  of  the  bladder,  253 

Caruncle,  urethral,  707 

Castration  for  enlarged  prostate,  423 

Casts,  blood,  534 
urinary,  22 

Chordee,  447 

treatment  of,  492 

Chtlueia,  644 

synonyms,  644 ;  definition,  644 ; 
character  of  the  urine,  644 ;  filaria 
sanguinis  hominis  in,  645 ;  etiology 
and  pathology,  646 ;  parasitic,  646 ; 
non -parasitic,  651 ;  distribution, 
652 ;  symptomatology,  652  ;  progno- 
sis, 654 ;  treatment,  654 ;  biblio- 
grapiiy,  058 
albuminuria  explained  by,  617 

Cirrhosis  of  the  kidney,  86 

Cohnheim,  intluencc  of,  in  renal  pathol- 
ogy. 14 


Colic,  renal,  143 

in  hsematuria,  548 

Coma,  ursemic,  36 

Conjunctivitis,  gonorrhoeal,  459 

Convulsions,  uraemic,  35 

Coruil's  classification  of  diseases  of  the 
kidney,  14 

Cowperitis,  449 
treatment,  495 

Craw-craw,  647 

Cystine,  composition  of,  618 
in  the  urine,  see  Cystinuria 
tests  for,   618 

Cystinuria,  618 

character  of  the  urine,  618 ;  causa- 
tion, 620  ;  clinical  aspects,  621 ; 
treatment,     622 ;    bibliography,   656 

CvsTi-rts,  223 

etiology,  223 ;  treatment  of  acute, 
225,  228;  metastatic,  225;  of  ob- 
struction, 227  ;  treatment,  229  ;  in 
spinal  cord  diseases,  231 ;  vesical 
atony,  232 ;  in  the  female,  233 ; 
possibility  of  calculus  in  chronic, 
234 ;  membranous,  234 ;  toilet  of 
the  bladder,  235 ;  tubercular  ulcer- 
ation, 240  ;  drainage  of  the  bladder, 
241 
gonorrhoeal,  449 

treatment,  495 
in  the  female,  233,  722 
suppurative  pyelonephritis  second- 
ary to,  105 

Cystocele  in  the  female,  710 

Cystoscopy,  electric,  260 
in  the  female,  673 

Cystotomy,  suprapubic,  308 

Cysts,  hydatid,  of  the  kidneys,  162 
mucous,  of  the  ureters,  193 
of  the  bladder,  255 
psorospermial,  of  the  ureters,  193 

Delafield,  Francis,  on  Diseases  of  the 

Kidneys,  1 
Delirium,  ursemic,  36 
Diabetes  insipidus,  641 
Diabetes  mellitus,  vicarious  oxaluria  in, 

637 
Dickinson's  classification  of  diseases  of 

the  kidney,  8 
Diuresis,  excessive,  640 


730 


INDEX  TO  VOLUME  I. 


Dropsy,  23 
Dyspnoea,  ursemic,  37 

Eclampsia,  Ptierpekal,  100 

morbid    anatomy,    100 ;     etiology, 

101 ;    symptoms,    103 ;    treatment, 

103 

convulsions  of,  35 
Electrolysis  in  urethral  stricture,  523 
Enchondroma  of  the  bladder,  255 
Epididymitis,  450 

symptoms,  451 ;  treatment,  495 
Exertion,  albuminuria  after,  29 

renal  congestion  after,  40 
Eye,  gonorrhceal  affections  of  the,  458 


Fenwick,  E.  Hurry,  on  Diseases  of  the 

Urine,  525 
Fever  in  uraemia,  36 
Fibrinuria,  532,  617 

Fibroma,  dendritic,  of  the  female  blad- 
der, 725 
of  the  bladder,  253 
Filaria  sanguinis  hominis    in    chyluria, 
645 
appearance  of,  in  the  blood  at  night 
only,  654 
Fistulae,  suprapubic  vesical,  374 
renal,  135 
ureteral,  198 

in  the  female,  718 
urethro-vaginal,  703 
vesical,  269,  375 
vesico-intestinal,  369 
vesico-rectal,  376 
vesico- vaginal,  275,  713 
Folliculitis,  urethral,  448 

treatment  of,  493 
Foreign  bodies  in  the  bladder,  313 

in    the    rectum,    vesical    symptoms 

from,  323 
in  the  urethra,  217,  437 
Frerichs'  classification  of  diseases  of  the 

kidney,  5 
Friedlander,    teachings    of,    concerning 
glomerulo-nephritis,  14 

Galacturia,  644  (see  Chyluria) 
Gleet,  481 


Gleet,  causes,  482 ;  varieties,  483 ;  dura- 
tion, 486 ;  treatment,  487 

Glomerulo-nephritis,  53,  63 
chronic,  69 

Gonorrhcea,  442 

predisposing  causes,  443 ;  mode  of 
contagion,  443 ;  morbid  anatomy, 
445  ;  complications,  447  ;  treatment, 
461 ;  abortive  treatment,  464 ;  ra- 
tional or  methodical  treatment,  466 ; 
general  treatment,  466 ;  internal 
medication,  471 ;  local  medication, 
476 ;  chronic,  481 ;  treatment  of  the 
complications  of,  493 
in  the  female,  urethritis  in,  704 

Gonorrhceal  Rheumatism,  453 

symptoms,  455 ;  varieties,  456 ; 
treatment,  497 

Gouty  kidneys,  ascending  pyelitis  due  to 
instrumentation  in,  605 

Gravel,  137 

Gull  and  Sutton,  classification  of  diseases 
of  the  kidney  by,  13 

HEMATURIA,  33,  537 

causes,  538  ;  diagnosis  of  source  and 
cause,  539  ;  symptomless,  545 ;  renal 
group,  546 ;  vesical  group,  553 ;  ac- 
companied by  other  urinary  symp- 
toms, 559 ;  treatment,  577 ;  treat- 
ment of  causes,  580 ;  bibliography, 
655 

after  certain  forms  of  diet,  543 
albuminuria  explained  by,  616 
critical  examination  of  the  symptoms 

in,  540 
dangers  of  instrumental  examination 

in,  539 
diagnosis  of  the  source  and  cause  of, 

539 
diagnostic  significance  of  the  effects 

of  rest,   abrupt  movements,    and 

exercise  in,  544 
endemic,  364 
following  slight    indirect  violence, 

diagnostic  significance  of,  543 
in  benign  tumors  of  the  bladder,  554, 

573 
in  chronic  Bright's  disease,  550 

treatment  of,  581 
in  cystic  renal  disease,  567 


INDEX  TO  VOLUME  I. 


731 


Haematuria  in  malignant  disease  of  the 
bladder,  555,  583 
in  malignant  disease  of  the  kidney, 
546,  568 
treatment,  580 
in  prostatic  disease,  585 
in  renal  calculus,  144,  553,  561 

treatment,  583 
in  renal  congestion  from  heart  dis- 
ease, 553 
in  syphiloma  of  the  kidney,  551 
in  the  hemorrhagic  diathesis,  553 
in  tuberculosis  of  the  bladder,  573 

treatment,   584 
in  tuberculosis  of  the  kidney,  154, 
563 
treatment  of,  584 
in  vesical  calculus,  558,  570 

treatment,  585 
in  villous  growth  of  the  renal  pelvis, 

553 
of  renal  origin,  535,  546,  560 
of  senile  enlarged  prostate,  575 
of  urethral  origin,  574 

treatment  of,  493,  585 
of  vesical  origin,  553,  570 
other  urinary  symptoms  accompany- 
ing, 559 
symptomless,  545 
treatment  of,  577 
treatment  of  the  causes  of,  580 
Haemoglobin  and  albumin,   relationship 

between,  534 
Haemoglobinuria,  23 
Haemophilia,  haematuria  in,  553 
Harkison,  Reginald,  on  Diseases  of  the 
Bladder,  201 
on  Diseases  of  the  Kidneys  (Surgi- 
cal) and  of  the  Ureters,  112 
Headache,  uraemic,  33 
Heart,  haematuria  in  disease  of  the,  553 
lesions    of,    in    chronic    productive 
nepliritis,  88 
Hemiplegia,  unemic,  34 
Hemorrhage,  urinary,  see  Hematuria 
Hernia  of  the  bladder,  247 

HYDRONPiPniiORIS,   127 

definition,  127  ;  etiology,  127  ;  prog- 
nosis,   130 ;   symptoms    131  ;    treat- 
ment, 133 
and  calculous  pyelo-nephritis,  160 


Hydatid  cyst  bursting  into  the  renal  pel- 
vis, 596 
of  the  abdomen  causing    hydrone- 
phrosis, 133 
of  the  kidney,  163 
Hypospadias  in  the  female,  696 

Incontinence,  urinary,  from  malposi- 
tion of  a  ureter,  198 

Inflammations,  chronic  productive,  pre- 
disposition to,  17 

Insomnia,  uraemic,  33 

Johnson,  George,  classification  of  dis- 
eases of  the  kidney  by,  6 

Kidneys,    Acute  Congestion  of  the, 
38 
definition,  38  ;  etiology,  38  ;  morbid 
anatomy,  39 ;   symptoms,    39 ;    va- 
rieties, 39 ;  treatment,  39 

Kidneys,     Acute    Degeneration    op 
the,  45 
definition,    45 ;  synonyms,  45 ;  eti- 
ology,   45 ;    morbid    anatomy,   48 ; 
symptoms,  48 ;  treatment,  49 

Kidneys,  abscesses  in  the,  104 
anatomy  of  the,  3 
arterio-sclerotic,  86 
cancer   of,  treatment  of   haematuria 
from,  580 

Kidneys,      Chronic     Congestion     op 
the,  40 
etiology,  41  ;    morbid  anatomy,  41 ; 
symptoms,  43 ;  treatment,  44 

Kidneys,    Chronic  Degeneration   op 

THE,  49 

definition,  49 ;  synonyms,  49 ;  etiol- 
ogy, 49 ;  morbid  anatomy,  50 ; 
symptoms,  50 ;  treatment,  51 

Kidneys,  cirrhosis  of  the,  86 

classifications  of  diseases  of  the,  5 
cystic  disease  of,  haematuria  in,  567 
deformities  and  malpositions  of  the, 

159 
differential  diagnosis  between  tuber- 
culosis and  calculus  of  the,  566 

Kidneys,  Diseases  of  the,  3 

anatomy,  3 ;  classification,  5 ;  the 
urine,  30  ;  dropsy,  23  ;  albuminuria, 


732 


INDEX  TO  VOLUME  I. 


26  ;  ura3mia,  29 ;  acute  congestion, 
38 ;  chronic  congestion,  40  ;  acute 
degeneration,  45  ;  chronic  degenera- 
tion, 49  ;  acute  productive  (or  diffuse) 
nephritis,  62 ;  chronic  productive 
(or  diffuse)  nephritis  -with  exuda- 
tion, 69  ;  chronic  productive  nephri- 
tis without  exudation,  86;  puerperal 
eclampsia,  100  ;  suppurative  nephri- 
tis, 103  ;  tubercular  nephritis,  106  ; 
new  growths  of  the  kidney,  107 ; 
bibliography,  109 
Kidneys,  enlargement  of  the,  significance 

of,  in  the  diagnosis  of  hrematuria, 

536 
fatty,  49 

fistulas  of  the,  125 
granular  degeneration  of  the,  86 
hematuria  in,  550 
polyuria  in,  643 
hemorrhage  from  the,  535 
horseshoe,  159 
hydatid  of  the,  162 
injuries  of  the,  113 
large  white,  69 
malignant  disease  of,  h«maturia  in, 

546,  568 
movable,  118 
new  growths  of  the,  107 
pain  in  the,  in  vesical  disease,  576 
parenchymatous  degeneration  of  the, 

45 
solitary,  160 
stone  in  the,  137 

hsematuria  in,  552,  561 
pyelitis  from,  601 
suppurative    inflammation    of    the, 

103,  120,  122 
surgical,  122 
Kidneys,  Surgical   Diseases  of  the, 

113 
injuries  of  the  kidney,  113;  movable 
kidney,  118;  perinephritic  and 
nephritic  suppurations,  120 ;  surgi- 
cal kidney,  122 ;  hydronephrosis, 
127 ;  pyonephrosis,  134 ;  renal  cal- 
culus, 137  ;  renal  tuberculosis,  152  ; 
deformities  and  malpositions  of  the 
kidney,  159  ;  hydatid  of  the  kidney, 
162 ;  tumors  of  the  kidney,  165 ; 
bibliographical  references,  199 


Kidneys,    syphiloma  of  the,   hsematuria 
in,  551 
tenderness  of  the,    significance  of, 

536 
tuberculosis  of  the,  106,  152,  602 
haematuria  in,  563 
treatment,   610 
Kidneys,  Tumors  of  the,  165 

varieties,    165  ;  diagnosis,  167  ;  ma- 
lignant, 170  ;  symptoms,  170  ;  treat- 
ment, 171 
Kidneys,  villous  growth  in  the  pelves  of 
the,  haematuria  in,  553 
washing  out  the  pelves  of  the,  in  the 

female,  690 
waxy,  69 

wounds  of  the,  113 
Klebs'    classification  of  diseases  of    the 
kidney,  9 

Lactic  fermentation  in  cystitis  with  am- 
moniacal  decomposition,  239 

Langhans,     teachings     of,     concerning 
glomerulo-uephritis,  14 

Lime,  amorphous  phosphate  of,  624 
crystallized  phosphate  of,  624 
oxalate,  deposition  of,  635 

Litholapaxy,  284 

Lithotomy,  300 

lateral,     301 ;    median,  304 ;    supra- 
pubic, 308 

LiTHOTRITY,    284 

historical,  284 ;  instruments  for, 
285 ;  operation,  283 ;  removal  of 
fragments,  288 ;  accidents  occurring 
during,  294  ;♦  after-treatment,  296  ; 
in  boys,  300 
Lymph  scrotum,  filaria  sanguinis  hominis 

in,  647 
Lymphangitis  of  the  penis,  complicating 

gonorrhoea,  461 
Lymphatic  vessels,  lesions  of,  in  chyluria, 

646 
Lydstox,  G.  Frank,  on  Diseases  of  the 
Male  Urethra,  431 
on  Diseases  of  the  Prostate,  327 

Mahomed's  theory  of   the    relation   of 

Bright's  disease  to  arteritis,  18 
Mania,  phosphaturia  in,  633 
Meatus,  urethral,  stricture  of  the,  519 


INDEX  TO   VOLUME   I. 


733 


Meningitis,  acute,  phosphaturia  in,  633 
Mons  ureteris,  670,  683 
Mucus  in  the  urine,  a  sign  of  renal  cal- 
culus, 144 
Myoma  of  the  bladder,  252 

of  the  prostate,  256 
Myxoma  of  the  bladder,  252 

Nauwerck,    teachings    of,     concerning 
glomerulo-nephritis,  14 

Nephritis,  Acute    Exudative,    52 
definition,  52  ;  synonyms,  52  ;  etiol- 
ogy, 52  ;  morbid  anatomy,  53  ;  symp- 
toms, 56  ;  prognosis,    60  ;  treatment, 
60 

Nephritis,  Acute  Productive  (or 
Diffuse),  62 
definition,  62 ;  synonyms,  62  ;  etiol- 
ogy, 62 ;  morbid  anatomy,  64 ; 
symptoms,  65 ;  prognosis,  67 ; 
treatment,  67 

Nephritis,  Chronic  Productive  (or 
Diffuse)  with  Exudation,  69 
definition,  69 ;  synonyms,  69 ;  etiol- 
ogy, 71  ;  morbid  anatomy,  72 ; 
symptoms,  78 ;  course,  82 ;  treat- 
ment, 84 

Nephritis,  Chronic  Productive, 
without  Exudation,  86 
definition,  86 ;  synonyms,  86 ;  etiol- 
ogy, 86;  morbid  anatomy,  86;  com- 
plicating lesions,  88  ;  symptoms,  93  ; 
course,  96 ;  treatment,  99 

Nephritis,  catarrhal,  52 

chronic  desquamative,  69 
chronic  diffuse,  69 
chronic  indurative,  86 
chronic  parenchymatous,  49,  69 
convulsions  in,  35 
croupous,  52,  62 
desquamative,  52 
interstitial,  86 
parenchymatous,  45,  52,  62 
suppurative,  103,  120 
tubal,  52 

tubercular,  106,  152,  602 
h;i;maturia  in,  563 
treatment  of,  610 

Nephrectomy,  146,  149 

Nephro-lithotomy,  146,  148 

Nephrotomy,  146,  147 


Neubauer's  method  of  the  quantitative 
estimation  of  oxalic  acid  in  the  urine, 
634 

Neuroses,  prostatic,  338 

Ophthalmia,  gonorrhceal,  458 

Orchitis,  450 

symptoms,  451  ;  treatment,  495 

Osteomalacia,  phosphaturia  in,  632 

Oxalates  in  the  urine,  22,  633  (see  Oxal- 
uria) 

Oxalic  acid,  tests  for,  634 

OXALURIA,  633 

definition,  633;  micro-chemical  tests, 
634  ;  appearance  of  the  urine,  635  ; 
deposit  of  oxalate  of  lime,  635  ;  clin- 
ical idiopathic  oxaluria  (oxaluria 
neurosa) ,  637  ;  treatment,  639  ;  bib- 
liography, 657 

Pachydermia  vesicae,  234 

Pain,  renal,  in  vesical  disease,  576 
vesical,  in  renal  disease,  576 

Papilloma  of  the  bladder,  253 
of  the  female  bladder,  725 

Pelvis,  renal,  washing  out  the,  in  the 
female,  690 

Penis,  vegetations  of  the,  460 
treatment,  499 

Perinephritis,  suppurative,  120 

Phlegmon,  peri-urethral,  448 
treatment,  493 

Phosphates  in   the  urine,    22,   623    (see 
Phosphaturia) 
detection  of,  626 
of  lime,  amorphous,  624 
stellar,  624 
the  earthy,  624 
triple,  625 

Phosphaturia,  628 

excretion  of  phosphoric  acid  and  its 
salts,  623 ;  detection  of  phosphates, 
626  ;  estimation  of  phosphoric  acid, 
626;  transient  phosphatic  urine,  628  ; 
secondary  phosphatic  deposits  in 
septic  urine,  629  ;  true  phosphaturia, 

629  ;  clinical  features  and  symptoms, 

630  ;  causation  ;  632  ;  treatment,  633  ; 
bibliography,  657 

Phosphoric    acid,    excretion   of,    in   the 
urine,  623 
in  the  urine,  estimation  of,  626 


734 


INDEX  TO  VOLUME  I. 


Polydipsia,  640 

Polypus  of  the  female  urethra,  708 

Polyuria,  640 

diabetes  insipidus,  641 ;  in  chronic 
Bright's  disease,  643 ;  from  direct 
vesico-prostatic  irritation,  644 

Posthitis,  460 

treatment,  499 

Prostate,  abscess  of  the,  358,  361,  373 
anatomy  of  the,  339 
anomalies  of  development  of  the,  334 
calculus  of  the,  397 
cancer  of  the,  256,  396 

Prostate,  Diseases  of  the,  329 

anatomy,  329;  physiology,  333; 
anomalies  of  development,  334  ;  in- 
juries, 335  ;  neuroses,  338  ;  hyper- 
aemia,  343 ;  acute  prostatitis,  350 ; 
chronic  prostatitis,  375  ;  tuberculo- 
sis, 388  ;  cancer,  396  ;  calculus,  397  ; 
hypertrophy,  399 ;  bibliography, 
428 

Prostate,  enlargement  of,  acute  ascend- 
ing pyelitis  following  the  removal 
of  large  amounts  of  urine  in,  606 
function  of  the,  333 
hsematuria  in  diseases  of  the,  538 

Prostate,  Hyperemia  op  the,  343 
etiology,  344  ;  symptoms,  346  ;  treat- 
ment, 349 

Prostate,  hyperesthesia  of  the,  339 

Prostate,  Hypertrophy  of  the,  399 
etiology,  399  ;  varieties,  406  ;  bar  at 
the  vesical  neck,  410 ;  dimensions, 
410;  frequency,  411;  morbid  anat- 
omy, 411 ;  symptoms,  414  ;  diagno- 
sis, 418 ;   treatment,  420 

Prostate,  inflammation  of  the,  see  Pros- 
tatitis 
injuries  of  the,  335 
miliary  abscesses  of  the,  358 
myoma  of  the,  256 
neuralgia  of  the,  339 
neuroses  of  the,  338 
polyuria  in  affections  of  the,  644 
sarcoma  of  the,  256 
senile  enargement  of  the,  heematuria 
of,  575 

Prostate,  Tuberculosis  of  the,   257, 
388 
varieties,  388 ;  etiology,  389  ;  morbid 


anatomy,  390 ;  symptoms  and  diag- 
nosis, 393 ;  treatment,  395 

Prostate,  tumors  of  the,  256 
treatment,  258 
vpounds  of  the,  335 

Prostatitis,  Acute,  350 

etiology,  351 ;  varieties,  358 ;  mor- 
bid anatomy,  363  ;  symptoms,  365  ; 
diagnosis,  367 ;  prognosis,  369 ; 
treatment,   370 

Prostatitis,  Chronic,  375 

varieties,  375  ;  etiology,  375  ;  follic- 
ular or  parenchymatous  form,  377 ; 
symptoms,  379 ;  morbid  anatomy, 
382;  treatment,  385 

Prostatitis,  diffuse,  358,  381 
follicular,  358,  377,  379 
para-,  359 

parenchymatous,  358,  377,  379 
suppurative,  358,  361.  373 

Psychoses  from  prostatic  irritation,  341 

Pus  in  the  urine,  see  Pyuria 

Pyaemia,  pyuria  in,  597 

Pyelitis,  599 

acute  pritaary,  599 
treatment,  609 
ascending,  604 

treatment,  610 
calculous,  601 
chronic,  600 

treatment,  609 
secondary,  .604 
traumatic,  603 
tubercular,  602 
treatment,  610 

Pyelonephritis,  suppurative,  105 

Pyelonephrosis,  609 

Pyonephrosis,  134,  600 

Pyuria,  586 

micro-chemical  characters  and  tests 
for  pus,  586 ;    sources  of  pus,  587 ; 
albuminuria    associated    with,  589; 
significance  of,   591 ;    extra-urinary 
sources,  594  ;   chief  urinary  diseases 
producing,     598 ;     treatment,    608 ; 
prognosis,     614;     albuminuria    ex- 
plained by,  615 ;  bibliography,  655 
in  renal  calculus,  144 
of  urethral  origin,  613 
of  vesical  origin,  607 
treatment,  612 


INDEX  TO   VOLUME  I. 


735 


Rayek's  classification  of  diseases  of  the 

kidney,  5 
Rectum,   foreign  bodies, in  the,   vesical 

symptoms  from,  223 
Reflex,  reno- vesical,  592 
Retention  of  urine  complicating  gonor- 
rhoea, 448 
treatment,  494 
Rheumatism,  Gonorrhceal,  453 

symptoms,     455 ;      varieties,      456 ; 
treatment,  497 
Rindfleisch's  classification  of  diseases  of 

the  kidney,  11 
Rokitansky's  classification  of  diseases  of 

the  kidney,  5 
Rosenstein's  classification  of  diseases  of 
the  kidney,  11 


Trigonum,  vesical,  in  the  female,  hyper- 

semia  of  the,  734 
Tuberculosis,  prostatic,  257,  388 
renal.  106,  152,  602 

differential   diagnosis  of,    from 

calculus,  566 
hsematuria  in,  563 
secondary  to  vesical,  604 
treatment,  610 
ureteral,  193 

vesical,  hsematuria  in,  573 
Tumors  of  the  bladder,  252 
in  the  female,  725 
treatment,  258 
of  the  kidneys,  107,  165 
of  the  prostate,  256 
treatment,  258 


Sahcoma  of  the  bladder,  252 

in  the  female,  725 
of  the  kidney.  107,  170 
of  the  prostate,  256 
of  the  urethra  in  the  female,  708 
Stricture  of  the  female  urethra,  698 
of  the  male  urethra,  499 

congenital,  506 

congestive,  505 

diagnosis,  502,  512 

electrolysis  for,  522 

hsematuria  from,  574 

irritable,  treatment  of,  522 

inflammatory,  505,  507 

localization  of,  513 

morbid  anatomy,  509 

operation  for,  520 

organic,  505,  507 

prognosis,  513 

spasmodic,  501 

symptoms,  511 

traumatic,   506 

treatment,  504,  516,  522 
Syphilis,  renal,  hsematuria  in,  551 

Tannin,  formation  of  cystin  from,  620 

Tension,  arterial,  urseniic,  38 

Testicle,  examination  of,  in  the  diagnosis 

of  the  source  of  hsematuria,  539 
Three-glass  test  for    pus  in  the  urine, 

589 
Traube,  recognition  of  chronic  congestion 

of  the  kidney  by,  7 


Ulcers  of  the  female  bladder,  T25 
Urachus,  patent,  247 
Ursemia,  29 

symptoms  of,  33 
Urates  in  the  urine,  22 
Urea,  absence  of,  in  injuries  to  the  ure- 
ters, 175 
excretion  of,  21 
Ureters,  affections  of,  causing  hsematu- 
ria, 537 
catheterization  of  the,  in  man,  181 

in  woman,  684 
dilatation  of  the,  195 
Ureters,  Diseases  of  the,  171 

injuries    of    the    ureters,    172 ;    ob- 
struction of  the  ureters,   181 ;   con- 
genital and  acquired  malformations 
of  the  ureters,  194 ;  ureteral  flstulse, 
198 ;    bibliographical  references,  200 
Ureters,  female,  asepsis  in  the  examina- 
tion of  the,  693 
methods  of  examining  the,  671 
obtaining  urine   from,    without 

catheterization,  688 
sounding  and  catheterizing  the, 

684 
washing  out  the,  690 
fistulse  of  the,  198 
Ureters,  Injuries  of  the,  172 

absence  of  symptoms,  173  ;  extrava- 
sation of  urine,  174 ;  stricture  fol- 
lowing, 175 ;  treatment,  175  ;  indi- 
cations for  operation,  176  ;   choice  of 


736 


INDEX  TO  VOLUME   I. 


operation,  178  ;  lateral  implantation, 
180 
Ureters,  malformations  of  tlie,  194 
Ureters,   Obstruction  of  the,  181 
stricture,   181 ;    calculus,   183 ;   sup- 
pression of  urine,  187 ;   character  of 
the  urine  in,    187 ;   treatment,   188 ; 
mucous    cysts,    193 ;    tuberculosis, 
193  ;  psorospermial  cysts,  193  ;   can- 
cer, 193 ;  gumma,  194 
obstruction  of,  leading  to  hydrone- 
phrosis, 127 
Ureters,  orifices  of  the,  670,  683 
stone  in  the,  183 
tuberculosis  of  the,  193 
Urethra,   female,   abscess    beneath    the, 
705 
anatomy  of  the,  664 
asepsis    in  the   examination  of 

the,  693 
calculus  of  the,  707 
carcinoma  of  the,  708 
caruncles  of  the  707 
condyloma  of  the,  707 
concretions  in  the,  708 
dilatation  of  the,  700 
Urethra,  Female,  Diseases  of  the, 
695 
malformations,    695 ;    displacement, 
696 ;   stricture,  698 ;    general  dilata- 
tion,   700 ;    partial    dilatation,    703 ; 
urethro-vagiual  fistula,  702  ;  inflam- 
matory affections,  703 ;  sub-urethral 
abscess,  705  ;   calculus,  707  ;  condy- 
loma, 707  ;    caruncles,  707  ;   polyps, 
708  ;   concretions,    708 ;    carcinoma, 
708 ;  sarcoma,  708 
Urethra,   female,    displacements   of  the, 
696 
examination  of  the,  671,  692 
inflammatory  affections  of  the, 

703 
malformations  of  the,  695 
new  growths  of  the,  707 
polyps  of  the,  708 
sarcoma  of  the,  708 
stricture  of  the,  698 
male,  anatomy  of  the,  433 
Urethra,  Male,  Diseases  of  the,  433 
anatomy  of  the   urethra,    433 ;    in- 
juries,   435 ;    foreign    bodies,    437 ; 


urethritis,  437 ;  gonorrhoea,  442 ; 
complications  of  urethritis,  447 ; 
treatment  of  urethritis,  461 ;  chronic 
urethritis,  481 ;  treatment  of  the 
complications  of  urethritis,  492 ; 
stricture,  499 ;  spasmodic  stricture, 
501 ;  congestive  or  inflammatory 
stricture,  505 ;  organic  stricture, 
505;  bibliography,  523 

Urethra,  male,  foreign  bodies  in  the,  217, 
437 
inflammation  of  the,  437 
injuries  of  the,  435 

Urethra,   Male,  Stricture   of   the, 
499 
varieties,  500 ;  spasmodic,  501 ;  con- 
gestive   or  inflammatory,    505 ;    or- 
ganic, 505  ;  traumatic,  506  ;  congeni- 
tal,   506 ;    organic,  of  inflammatory 
origin,  507 ;    morbid  anatomy,  509 
symptoms,     511 ;    diagnosis,     512 
prognosis,     513 ;    localization,   513 
treatment,  516 
hsematuria  in,  574 

Urethritis,  437 

varieties,  439 ;  simple,  440 ;  gono- 
coccal or  specific  (see  Oonorrlum), 
442  ;  morbid  anatomy,  445  ;  compli- 
cations, 447  ;  treatment,  461 ;  abor- 
tive treatment,  464 ;  rational  or 
methodical  treatment,  466  ;  internal 
medication,  471 ;  local  medication, 
476 ;  chronic,  481 ;  treatment  of 
chronic,  487  ;  treatment  of  the  com- 
plications, 492 

Urethritis  in  the  female,  703 
simple,  440 

Urethro-vaginal  fistula,  702 

Urethro-vaginal  septum,  abscess  of  the, 
705 

Urinary  organs,  female,  methods  of  ex- 
amining the,  671 

Urine,  albumin  in  the,  26,  615  (see  Albu- 
miiiuria) 
blood  in  the,  22,  257  (see  EdBmaturia) 
casts  in  the,  22 

characters  of  the,  in  ureteral  obstruc- 
tion, 187,  197 
chylous,  see  Chyluria 
constituents  of  the,  21 
cystine  in  the,  see  Gystinuria 


INDEX  TO   VOLUME   I. 


737 


Urine,  Diseases  of  the,  527 

bsematuria,  527  ;  pyuria,  586 ;  acci- 
dental albuminuria,  615  :  cystinuria, 
618  ;  phosphaturia,  623  ;  oxaluria, 
633;  polyuria,  640;  chyluria,  644; 
bibliography,  655 

Uriue,  examination  of,  for  blood,  529 
gelatinization  of,  532,  617 
incontinence  of,  from  malposition  of 

a  ureter,  198 
increased  excretion  of,  see  Polyuria 
mucus  in  the,  a  sign  of  renal  calcu- 
lus, 144 
oxalates  in,  see  Oxaluna 
phosphates  in  the,  see  Phosphaturia 
phosphatic,  transient,  628 
pus  in,  see  Pyuria 
quantity  of,  20 
retention  of,  244 

complicating  gonorrhoea,  448 

Vol.  I.— 47 


Urine,  retention  of,  treatment,  i9 

septic,  secondary  pliosphatic  deposits 

in,  629 
specific  gravity  of,  21 
suppression  of,  in  obstruction  of  the 

ureter  of  a  solitary  kidney,  187 

Varicocele,    a  sign   of   cancer  of   the 

kidney,  548 
Vegetations,  venereal,  460 

treatment,  499 
Virchow's   classification    of    diseases  of 

the  kidney,  7 
Vomiting,  ureemic,  36 

Weigert's  classification  of  diseases    of 
the  kidney,  12 

Ziegler's  classification  of  diseases  of  the 
kidney,  14 


RC41 


sts 

1 


